=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174672109
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NESEMIO SANTIAGO D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 880 INDIAN TRAIL LILBURN RD NW
-----------------------------------------------------
City | LILBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30047-6844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-921-1498
-----------------------------------------------------
Fax | 770-921-6702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 544 RIVULETT CT
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30043-5487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-921-1498
-----------------------------------------------------
Fax | 770-921-6702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIR007788
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------