Healthcare Provider Details

I. General information

NPI: 1629264072
Provider Name (Legal Business Name): DCLC TWO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 MECHANIC ST
DAHLONEGA GA
30533-1337
US

IV. Provider business mailing address

PO BOX 599
DAHLONEGA GA
30533-0010
US

V. Phone/Fax

Practice location:
  • Phone: 706-864-5362
  • Fax: 706-864-5761
Mailing address:
  • Phone: 706-864-5362
  • Fax: 706-864-5761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number07276
License Number StateGA

VIII. Authorized Official

Name: CURTIS FEDORCHUK
Title or Position: PROVIDER
Credential:
Phone: 706-864-5362