=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770883985
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNESAW MOUNTAIN CLINC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2010
-----------------------------------------------------
Last Update Date | 10/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 850 KENNESAW AVE C-9
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-427-0119
-----------------------------------------------------
Fax | 770-485-3018
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 850 KENNESAW AVE C-9
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-427-0119
-----------------------------------------------------
Fax | 770-485-3018
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JEFFREY MICHAEL COMANOR
-----------------------------------------------------
Credential | DC ND
-----------------------------------------------------
Telephone | 770-427-0119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 004810
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------