Healthcare Provider Details

I. General information

NPI: 1255489712
Provider Name (Legal Business Name): THACKER CHIROPRACTIC CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 HIGHWAY 138 SE SUITE 600
CONYERS GA
30013-2079
US

IV. Provider business mailing address

1815 HIGHWAY 138 SE SUITE 600
CONYERS GA
30013-2079
US

V. Phone/Fax

Practice location:
  • Phone: 770-860-8333
  • Fax: 770-860-8833
Mailing address:
  • Phone: 770-860-8333
  • Fax: 770-860-8833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR002342
License Number StateGA

VIII. Authorized Official

Name: DR. MITCHEL L. THACKER
Title or Position: CO-OWNER
Credential: D.C
Phone: 770-860-8333