Healthcare Provider Details

I. General information

NPI: 1063128007
Provider Name (Legal Business Name): JUAN SEBASTIAN REQUENA-FERRER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 01/24/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3417 CANTON RD BLDG 2
MARIETTA GA
30066-0018
US

IV. Provider business mailing address

3417 CANTON RD BLDG 2
MARIETTA GA
30066-0018
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-4804
  • Fax:
Mailing address:
  • Phone: 770-424-4804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR010957
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: