Healthcare Provider Details

I. General information

NPI: 1780092072
Provider Name (Legal Business Name): DR. FERNANDO OBALLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 OLD ALABAMA RD SUITE 119-317
ALPHARETTA GA
30022-5860
US

IV. Provider business mailing address

3000 OLD ALABAMA RD SUITE 119-317
ALPHARETTA GA
30022-5860
US

V. Phone/Fax

Practice location:
  • Phone: 678-736-1635
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIRO09060
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: