=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124603683
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DALE WESLEY DISBRO JR. DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2021
-----------------------------------------------------
Last Update Date | 03/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1640 POWERS FERRY RD SE STE 175
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30067-5491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-690-8959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2695 DELK RD SE APT C
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30067-6209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 151-767-7782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIR010515
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------