MEDICARE: MIRA CHIROPRACTIC CLINIC, 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	111N00000X	Chiropractor	CHIR008996	GA

General Provider Information

NPI Number	:	1184056061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRA CHIROPRACTIC CLINIC, LLC

Provider Business Mailing Address
First Line	:	575 DEKALB INDUSTRIAL WAY STE 105
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30030-1756
Country	:	US
Telephone Number	:	770-713-9394
Fax Number	:

Provider Business Practice Location Address
First Line	:	1511 PARK GROVE DR
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30046-4398
Country	:	US
Telephone Number	:	770-713-9394
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. MIRA ABDURASHID AHMED
Credential	:	D.C
Telephone Number	:	770-713-9394

Provider Enumeration Date	:	08/02/2013
Last Update Date	:	08/02/2013

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