Healthcare Provider Details

I. General information

NPI: 1356635023
Provider Name (Legal Business Name): NICHOLAS DWAYNE CARLISLE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2011
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3775 VENTURE DR BLDG K
DULUTH GA
30096-5102
US

IV. Provider business mailing address

10945 STATE BRIDGE RD STE 401-160
JOHNS CREEK GA
30022-8164
US

V. Phone/Fax

Practice location:
  • Phone: 678-878-3149
  • Fax: 404-420-2939
Mailing address:
  • Phone: 404-316-1190
  • Fax: 404-420-2939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR008621
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: