Healthcare Provider Details

I. General information

NPI: 1285794057
Provider Name (Legal Business Name): PETER GARY LAZARNICK D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

486 BANKHEAD HWY
CARROLLTON GA
30117-2445
US

IV. Provider business mailing address

40 FOGGY BOTTOM DR
CARROLLTON GA
30116-8047
US

V. Phone/Fax

Practice location:
  • Phone: 770-834-7477
  • Fax: 770-834-0251
Mailing address:
  • Phone: 770-834-7377
  • Fax: 770-834-0251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR001151
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: