1760717573 NPI number — MICHELLE KLOS D.C. INC.

Table of content: (NPI 1760717573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760717573 NPI number — MICHELLE KLOS D.C. INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHELLE KLOS D.C. INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHSIDE SPINAL CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760717573
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
604 PEBBLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30114-8867
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-697-9667
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
386 RACETRACK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCDONOUGH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30252-1022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-583-2982
Provider Business Practice Location Address Fax Number:
678-583-2984
Provider Enumeration Date:
10/12/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MONASTERSKI-KLOS
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
CHIROPRACTOR/OWNER
Authorized Official Telephone Number:
678-583-2982

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  CHIROO8486 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 202G35640 . This is a "MEDICARE OFFICE #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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