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General NPI Number Information
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NPI Number | 1538478508
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Entity Type | Organization
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Legal Business Name | GEORGIA CLINIC OF CHIROPRACTIC, LLC
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Dates
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Enumeration Date | 09/24/2010
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Last Update Date | 09/24/2010
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Provider Practice Location Address
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Address Line | 205 OLD BLACKSTONE CAMP RD
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City | MARTINEZ
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State | GA
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Zip | 30907-9459
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Country | US
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Telephone | 618-922-2948
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Fax |
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Provider Business Mailing Address
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Address Line | 205 OLD BLACKSTONE CAMP RD
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City | MARTINEZ
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State | GA
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Zip | 30907-9459
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARK LESLIE HUNTSMAN
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Credential | D.C.
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Telephone | 618-922-2948
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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 | CHIR008712
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License Number State | GA
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