1629221213 NPI number — LIFE OF GEORGIA CHIROPRACTIC CLINIC

Table of content: CORIN ELLEN PETERS CPHT (NPI 1689785537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629221213 NPI number — LIFE OF GEORGIA CHIROPRACTIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE OF GEORGIA CHIROPRACTIC CLINIC
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:
Provider Other Organization Name Type Code:
6
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:
1629221213
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1914 CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30904-4126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-733-2211
Provider Business Mailing Address Fax Number:
706-733-2271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1914 CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30904-4126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-733-2211
Provider Business Practice Location Address Fax Number:
706-733-2271
Provider Enumeration Date:
10/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
O.
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
706-733-2211

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0400X , with the licence number: 1346 , 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: 1376788406 . This is a "THIRD PARTY" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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