Healthcare Provider Details

I. General information

NPI: 1013033703
Provider Name (Legal Business Name): FISH FAMILY CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 W. CROSSVILLE ROAD
ROSWELL GA
30075
US

IV. Provider business mailing address

455 W. CROSSVILLE ROAD
ROSWELL GA
30075
US

V. Phone/Fax

Practice location:
  • Phone: 770-518-7700
  • Fax: 770-518-1030
Mailing address:
  • Phone: 770-518-7700
  • Fax: 770-518-1030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License NumberCHIRO02079
License Number StateGA

VIII. Authorized Official

Name: DR. GARY P FISH
Title or Position: OWNER
Credential: DC
Phone: 770-518-7700