Healthcare Provider Details

I. General information

NPI: 1972689347
Provider Name (Legal Business Name): ANDREI PETROVICH BOURDEINYI D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3155 ROSWELL RD NE SUITE 140
ATLANTA GA
30305-1821
US

IV. Provider business mailing address

1625 ROSWELL RD APT.138
MARIETTA GA
30062-3682
US

V. Phone/Fax

Practice location:
  • Phone: 404-231-1000
  • Fax: 404-231-5546
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR006547
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: