Healthcare Provider Details

I. General information

NPI: 1992950711
Provider Name (Legal Business Name): BETHLEHEM DAGNEW DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2008
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 HAMMOND DR NE SUITE G7110
ATLANTA GA
30328-5338
US

IV. Provider business mailing address

1140 HAMMOND DR NE SUITE G7110
ATLANTA GA
30328-5338
US

V. Phone/Fax

Practice location:
  • Phone: 770-901-9303
  • Fax:
Mailing address:
  • Phone: 770-901-9303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number6027
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: