Healthcare Provider Details

I. General information

NPI: 1427224724
Provider Name (Legal Business Name): EAGLE CHIROPRACTIC CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 EAGLES LANDING PKWY SUITE-10
STOCKBRIDGE GA
30281-5096
US

IV. Provider business mailing address

616 EAGLES LANDING PKWY SUITE-10
STOCKBRIDGE GA
30281-5096
US

V. Phone/Fax

Practice location:
  • Phone: 678-565-1500
  • Fax: 678-565-7411
Mailing address:
  • Phone: 678-565-1500
  • Fax: 678-565-7411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License NumberCH7373
License Number StateGA

VIII. Authorized Official

Name: DR. MICHAEL ANDREW BRUNO
Title or Position: PRESIDENT
Credential: D.C.
Phone: 678-565-1500