MEDICARE: KOPACETIC KHIROPRACTIC 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

General Provider Information

NPI Number	:	1700671948
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOPACETIC KHIROPRACTIC LLC.

Provider Business Mailing Address
First Line	:	6595 ROSWELL RD STE G
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-3152
Country	:	US
Telephone Number	:	404-969-5707
Fax Number	:

Provider Business Practice Location Address
First Line	:	1003 VIRGINIA AVE STE 200
Second Line	:
City	:	HAPEVILLE
State	:	GA
Zip	:	30354-1387
Country	:	US
Telephone Number	:	404-969-5707
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. KEONA FAVIS
Credential	:	DC
Telephone Number	:	318-800-1032

Provider Enumeration Date	:	04/09/2025
Last Update Date	:	11/21/2025

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