Healthcare Provider Details

I. General information

NPI: 1811169378
Provider Name (Legal Business Name): CENTENNIAL CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 03/25/2008
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 Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberGA005452
License Number StateGA

VIII. Authorized Official

Name: DR. MICHAEL J MORIBALDI
Title or Position: OWNER
Credential: DC
Phone: 770-649-1730