=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366182438
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTA CHIROPRACTIC AND REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2022
-----------------------------------------------------
Last Update Date | 03/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2053 STANTON RD
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30344-1311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-698-3682
-----------------------------------------------------
Fax | 833-623-4907
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2053 STANTON RD
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30344-1311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-698-3682
-----------------------------------------------------
Fax | 833-623-4907
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | ASHLEY WOOTEN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 912-224-1731
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------