=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184056061
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRA CHIROPRACTIC CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2013
-----------------------------------------------------
Last Update Date | 08/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1511 PARK GROVE DR
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30046-4398
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-713-9394
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 575 DEKALB INDUSTRIAL WAY STE 105
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-1756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-713-9394
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. MIRA ABDURASHID AHMED
-----------------------------------------------------
Credential | D.C
-----------------------------------------------------
Telephone | 770-713-9394
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIR008996
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------