=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932584083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 100 PERCENT CHIROPRACTIC ATLANTA SEVEN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2015
-----------------------------------------------------
Last Update Date | 06/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 BARRETT PKWY
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30066-3331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-324-1016
-----------------------------------------------------
Fax | 678-401-7647
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 BARRETT PKWY
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30066-3331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-324-1016
-----------------------------------------------------
Fax | 678-401-7647
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NICO STAPLES
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 678-324-1016
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIR009463
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------