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General NPI Number Information
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NPI Number | 1548867047
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Entity Type | Organization
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Legal Business Name | BRIDGE CHIROPRACTIC AND REHABILITATION LLC
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Dates
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Enumeration Date | 10/07/2020
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Last Update Date | 10/07/2020
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Provider Practice Location Address
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Address Line | 2850 JOHNSON FERRY RD STE 150
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City | MARIETTA
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State | GA
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Zip | 30062-8317
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Country | US
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Telephone | 770-518-8786
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Fax | 770-692-3659
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Provider Business Mailing Address
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Address Line | 2850 JOHNSON FERRY RD STE 150
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City | MARIETTA
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State | GA
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Zip | 30062-8317
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Country | US
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Telephone | 770-518-8786
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Fax | 770-692-3659
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Authorized Official
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Title or Position | OWNER/CHIROPRACTOR
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Name | DR. DERRYL DICKERSON
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Credential | DC
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Telephone | 770-518-8786
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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 |
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License Number State |
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