MEDICARE: TOWNE LAKE FAMILY CHIROPRACTIC

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	CHIR009726	GA

General Provider Information

NPI Number	:	1386194801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOWNE LAKE FAMILY CHIROPRACTIC

Provider Business Mailing Address
First Line	:	1000 WYNGATE PKWY
Second Line	:	200
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-6981
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 WYNGATE PKWY
Second Line	:	200
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-6981
Country	:	US
Telephone Number	:	770-592-1877
Fax Number	:	770-592-1876

Authorized Official
Title or Position	:	INSURANCE MANAGER
Name	:	KRISTA MORAN
Credential	:
Telephone Number	:	770-592-1877

Provider Enumeration Date	:	10/07/2016
Last Update Date	:	10/07/2016

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