=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255534095
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALISSIA F. HEWETT-MCNEIL D.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2007
-----------------------------------------------------
Last Update Date | 10/10/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8303 OFFICE PARK DR STE B
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-6935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-480-9159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5010 STARLA LANE
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 8043
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3649
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------