Healthcare Provider Details

I. General information

NPI: 1811342413
Provider Name (Legal Business Name): MEDIPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 05/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 HARRISON ROAD SUITE 400
LOGANVILLE GA
30052-8502
US

IV. Provider business mailing address

3955 HARRISON ROAD SUITE 400
LOGANVILLE GA
30052-8502
US

V. Phone/Fax

Practice location:
  • Phone: 770-496-0326
  • Fax:
Mailing address:
  • Phone: 770-496-0326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number15826
License Number StateGA

VIII. Authorized Official

Name: MISHEL CARR
Title or Position: OFFICE MANAGER
Credential:
Phone: 770-496-0326