Healthcare Provider Details

I. General information

NPI: 1538216924
Provider Name (Legal Business Name): RICHARD JOHN DE CARLO D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4686 S ATLANTA RD SE SUITE G
SMYRNA GA
30080-7080
US

IV. Provider business mailing address

4686 S ATLANTA RD SE SUITE G
SMYRNA GA
30080-7080
US

V. Phone/Fax

Practice location:
  • Phone: 404-794-4357
  • Fax: 404-794-8205
Mailing address:
  • Phone: 404-794-4357
  • Fax: 404-794-8205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number4813
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: