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General NPI Number Information
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NPI Number | 1134124514
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Entity Type | Individual
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Provider Name | NICHOLAS J DASTA DC
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Gender | Male
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Dates
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Enumeration Date | 06/14/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 5124 N HENRY BLVD
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-3232
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Country | US
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Telephone | 770-474-6680
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Fax | 770-474-3633
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Provider Business Mailing Address
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Address Line | 8222 YALE DR
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City | JONESBORO
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State | GA
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Zip | 30236-4046
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Country | US
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Telephone | 404-290-5374
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CHIR 007487
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License Number State | GA
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