Healthcare Provider Details

I. General information

NPI: 1972642296
Provider Name (Legal Business Name): TERESA GRACE FOURRE D.C., CNMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4080 HOLLY SPRINGS PKWY
CANTON GA
30115-7410
US

IV. Provider business mailing address

PO BOX 489
HOLLY SPRINGS GA
30142-0009
US

V. Phone/Fax

Practice location:
  • Phone: 770-345-7885
  • Fax: 770-345-7883
Mailing address:
  • Phone: 770-345-7885
  • Fax: 770-345-7883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCHIR006079
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: