MEDICARE: CHIROPRACTIC GAME CHANGERS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CHIR008695	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CHIR008695	OTHER	GA	CHIROPRACTIC LICENSE

General Provider Information

NPI Number	:	1538686258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIROPRACTIC GAME CHANGERS, LLC

Provider Business Mailing Address
First Line	:	2615 E WEST CONNECTOR STE 108
Second Line	:
City	:	AUSTELL
State	:	GA
Zip	:	30106-6854
Country	:	US
Telephone Number	:	770-943-1425
Fax Number	:	770-943-1452

Provider Business Practice Location Address
First Line	:	2615 E WEST CONNECTOR STE 108
Second Line	:
City	:	AUSTELL
State	:	GA
Zip	:	30106-6854
Country	:	US
Telephone Number	:	770-943-1425
Fax Number	:	770-943-1452

Authorized Official
Title or Position	:	OWNER/DC
Name	:	SAMUEL CLAVELL
Credential	:
Telephone Number	:	770-943-1425

Provider Enumeration Date	:	08/23/2017
Last Update Date	:	12/02/2022

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Directions to “CHIROPRACTIC GAME CHANGERS, LLC ” Practice Location

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