Healthcare Provider Details

I. General information

NPI: 1891066635
Provider Name (Legal Business Name): MICHAEL WAX D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 HAMMOND DR NE STE 110
ATLANTA GA
30328-5338
US

IV. Provider business mailing address

1140 HAMMOND DR NE STE 110
ATLANTA GA
30328-5338
US

V. Phone/Fax

Practice location:
  • Phone: 770-454-8300
  • Fax: 770-986-9962
Mailing address:
  • Phone: 770-454-8300
  • Fax: 770-986-9962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR005750
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: