Healthcare Provider Details

I. General information

NPI: 1598837296
Provider Name (Legal Business Name): STEVEN MARK THACKER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
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 NumberCHIROO3134
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: