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General NPI Number Information
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NPI Number | 1134355779
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Entity Type | Organization
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Legal Business Name | TUCKER NECK AND BACK, LLC
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Dates
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Enumeration Date | 06/10/2009
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Last Update Date | 06/10/2009
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Provider Practice Location Address
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Address Line | 4880 LAWRENCEVILLE HWY SUITE 13
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City | TUCKER
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State | GA
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Zip | 30084-2938
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Country | US
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Telephone | 770-621-5585
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Fax | 770-414-7355
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Provider Business Mailing Address
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Address Line | 4880 LAWRENCEVILLE HWY SUITE 13
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City | TUCKER
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State | GA
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Zip | 30084-2938
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Country | US
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Telephone | 770-621-5585
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Fax | 770-414-7355
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Authorized Official
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Title or Position | CEO
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Name | DR. TONY L BANGUILAN
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Credential | D.C.
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Telephone | 770-621-5585
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | CHIR0006452
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License Number State | GA
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