MEDICARE: TUCKER NECK AND BACK, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NR0400X	Rehabilitation Chiropractor	CHIR0006452	GA

General Provider Information

NPI Number	:	1134355779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TUCKER NECK AND BACK, LLC

Provider Business Mailing Address
First Line	:	4880 LAWRENCEVILLE HWY
Second Line	:	SUITE 13
City	:	TUCKER
State	:	GA
Zip	:	30084-2938
Country	:	US
Telephone Number	:	770-621-5585
Fax Number	:	770-414-7355

Provider Business Practice Location Address
First Line	:	4880 LAWRENCEVILLE HWY
Second Line	:	SUITE 13
City	:	TUCKER
State	:	GA
Zip	:	30084-2938
Country	:	US
Telephone Number	:	770-621-5585
Fax Number	:	770-414-7355

Authorized Official
Title or Position	:	CEO
Name	:	DR. TONY L BANGUILAN
Credential	:	D.C.
Telephone Number	:	770-621-5585

Provider Enumeration Date	:	06/10/2009
Last Update Date	:	06/10/2009

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Directions to “TUCKER NECK AND BACK, LLC ” Practice Location

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