Healthcare Provider Details

I. General information

NPI: 1295943967
Provider Name (Legal Business Name): COMPLETE BACK AND BODY CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 HIGHWAY 85 N
FAYETTEVILLE GA
30214-7315
US

IV. Provider business mailing address

1260 HIGHWAY 85 N
FAYETTEVILLE GA
30214-7315
US

V. Phone/Fax

Practice location:
  • Phone: 770-719-9166
  • Fax: 770-719-9136
Mailing address:
  • Phone: 770-719-9166
  • Fax: 770-719-9136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCHIRO07601
License Number StateGA

VIII. Authorized Official

Name: MRS. PATRICIA C. LASALATA
Title or Position: PRESIDENT
Credential:
Phone: 770-719-9166