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General NPI Number Information
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NPI Number | 1760694483
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Entity Type | Organization
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Legal Business Name | SELF ACTUALIZATION KINESIOLOGY
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Dates
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Enumeration Date | 05/04/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 455 EAST PACES FERRY ROAD 325
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City | ATLANTA
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State | GA
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Zip | 30305
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Country | US
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Telephone | 404-261-7504
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Fax | 404-477-3291
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Provider Business Mailing Address
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Address Line | 455 EAST PACES FERRY ROAD 325
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City | ATLANTA
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State | GA
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Zip | 30305
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Country | US
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Telephone | 404-261-7504
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Fax | 404-477-3291
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. EDWARD LINDSEY FREY
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Credential | DC
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Telephone | 404-261-7504
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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 | 2831
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License Number State | GA
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