Healthcare Provider Details

I. General information

NPI: 1740460336
Provider Name (Legal Business Name): PHILEMON ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2007
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MIRRAMONT LAKE DR
WOODSTOCK GA
30189-8214
US

IV. Provider business mailing address

111 NACOOCHEE WAY
CANTON GA
30114-9020
US

V. Phone/Fax

Practice location:
  • Phone: 678-445-7055
  • Fax: 678-445-0884
Mailing address:
  • Phone: 678-493-9765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIRO007996
License Number StateGA

VIII. Authorized Official

Name: KENNETH W KILGORE
Title or Position: SINGLE MEMBER
Credential: D.C.
Phone: 678-493-9765