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General NPI Number Information
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NPI Number | 1497174791
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Entity Type | Organization
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Legal Business Name | GREXA ENTERPRISES LLC
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Dates
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Enumeration Date | 04/15/2014
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Last Update Date | 04/15/2014
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Provider Practice Location Address
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Address Line | 1750 MARIETTA HWY STE 140
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City | CANTON
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State | GA
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Zip | 30114-3994
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Country | US
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Telephone | 770-213-7602
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Fax | 770-213-7604
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Provider Business Mailing Address
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Address Line | 2622 LAKE PARK BND
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City | ACWORTH
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State | GA
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Zip | 30101-6886
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Country | US
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Telephone | 404-375-1560
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MITCHELL D GREXA
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Credential | DC
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Telephone | 770-213-7602
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CHIR005316
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License Number State | GA
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