Healthcare Provider Details

I. General information

NPI: 1114078474
Provider Name (Legal Business Name): JORGE A BUENO D.C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5977 STEWART PKWY
DOUGLASVILLE GA
30135-2371
US

IV. Provider business mailing address

5977 STEWART PKWY
DOUGLASVILLE GA
30135-2371
US

V. Phone/Fax

Practice location:
  • Phone: 770-942-5575
  • Fax:
Mailing address:
  • Phone: 770-942-5575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number007057
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: