Healthcare Provider Details

I. General information

NPI: 1992889497
Provider Name (Legal Business Name): LISA N MIELCARSKI D.C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 01/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 NEWNAN ST
CARROLLTON GA
30117-3429
US

IV. Provider business mailing address

8 MOUNTAIN BROOKE DR
CARROLLTON GA
30116-6490
US

V. Phone/Fax

Practice location:
  • Phone: 770-834-6669
  • Fax: 770-834-4814
Mailing address:
  • Phone: 678-462-4402
  • Fax: 770-834-4814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIRO007252
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: