Healthcare Provider Details

I. General information

NPI: 1790043727
Provider Name (Legal Business Name): WEST COBB CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5041 DALLAS HWY SUITE 500
POWDER SPRINGS GA
30127-6458
US

IV. Provider business mailing address

5041 DALLAS HWY SUITE 500
POWDER SPRINGS GA
30127-6458
US

V. Phone/Fax

Practice location:
  • Phone: 770-919-7171
  • Fax: 770-218-0341
Mailing address:
  • Phone: 770-919-7171
  • Fax: 770-218-0341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR005581
License Number StateGA

VIII. Authorized Official

Name: FRED ROBERTO
Title or Position: OWNER/DOCTOR
Credential:
Phone: 770-919-7171