Healthcare Provider Details

I. General information

NPI: 1134355779
Provider Name (Legal Business Name): TUCKER NECK AND BACK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 06/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4880 LAWRENCEVILLE HWY SUITE 13
TUCKER GA
30084-2938
US

IV. Provider business mailing address

4880 LAWRENCEVILLE HWY SUITE 13
TUCKER GA
30084-2938
US

V. Phone/Fax

Practice location:
  • Phone: 770-621-5585
  • Fax: 770-414-7355
Mailing address:
  • Phone: 770-621-5585
  • Fax: 770-414-7355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCHIR0006452
License Number StateGA

VIII. Authorized Official

Name: DR. TONY L BANGUILAN
Title or Position: CEO
Credential: D.C.
Phone: 770-621-5585