Healthcare Provider Details

I. General information

NPI: 1609704642
Provider Name (Legal Business Name): GARRETT BOURES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3422 SIXES RD STE 110
CANTON GA
30114-9120
US

IV. Provider business mailing address

104 DOVERHOUSE ST
CANTON GA
30114-3147
US

V. Phone/Fax

Practice location:
  • Phone: 770-213-8890
  • Fax:
Mailing address:
  • Phone: 908-319-2787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR066667
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: