=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407993314
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK GRECO D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 PONCE DE LEON AVE NE STE 620B
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30308-1874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-885-1414
-----------------------------------------------------
Fax | 404-885-1476
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 650 PONCE DE LEON AVE NE STE 620B
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30308-1874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-885-1414
-----------------------------------------------------
Fax | 404-885-1476
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 6288
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------