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General NPI Number Information
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NPI Number | 1811268667
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Entity Type | Organization
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Legal Business Name | LAKESIDE CHIROPRACTIC WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 01/24/2012
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Last Update Date | 04/27/2012
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Provider Practice Location Address
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Address Line | 3750 PALLADIAN VILLAGE DR SUITE 330
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City | MARIETTA
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State | GA
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Zip | 30066-8200
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Country | US
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Telephone | 678-401-8207
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Fax | 866-248-6750
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Provider Business Mailing Address
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Address Line | 1208 KILLARNEY SE
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City | SMYRNA
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State | GA
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Zip | 30080-8515
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Country | US
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Telephone | 678-644-1990
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Fax | 866-248-6750
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Authorized Official
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Title or Position | CHIROPRACTOR/OWNER
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Name | DR. DALE ENOCH CALLAWAY
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Credential | D.C.
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Telephone | 678-401-8207
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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 | CHIR008802
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License Number State | GA
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