Healthcare Provider Details

I. General information

NPI: 1699859637
Provider Name (Legal Business Name): MICHAEL J MORIBALDI DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4343 SHALLOWFORD RD SUITE B6
MARIETTA GA
30062-5023
US

IV. Provider business mailing address

4343 SHALLOWFORD RD SUITE B6
MARIETTA GA
30062-5023
US

V. Phone/Fax

Practice location:
  • Phone: 770-649-1730
  • Fax: 770-649-1731
Mailing address:
  • Phone: 770-649-1730
  • Fax: 770-649-1731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number005452
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: