Healthcare Provider Details

I. General information

NPI: 1992048136
Provider Name (Legal Business Name): BODY CORE NEUROPATHY & SPINE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2013
Last Update Date: 04/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3855 SHALLOWFORD RD SUITE 510
MARIETTA GA
30062-4195
US

IV. Provider business mailing address

3855 SHALLOWFORD RD SUITE 510
MARIETTA GA
30062-4195
US

V. Phone/Fax

Practice location:
  • Phone: 770-993-6010
  • Fax: 770-993-6011
Mailing address:
  • Phone: 770-993-6010
  • Fax: 770-993-6011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCHIR008654
License Number StateGA

VIII. Authorized Official

Name: DR. ALICIA A CRUSSE
Title or Position: OWNER
Credential: D.C.
Phone: 770-993-6010