MEDICARE: DR. VINCENT C. BUBOLO D.C.

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	6956	GA

General Provider Information

NPI Number	:	1518919026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VINCENT C. BUBOLO D.C.

Provider Business Mailing Address
First Line	:	3195 ACWORTH DUE WEST RD NW
Second Line	:	STE. B
City	:	KENNESAW
State	:	GA
Zip	:	30152-2313
Country	:	US
Telephone Number	:	770-975-1299
Fax Number	:	770-975-1361

Provider Business Practice Location Address
First Line	:	3195 ACWORTH DUE WEST RD NW
Second Line	:	STE. B
City	:	KENNESAW
State	:	GA
Zip	:	30152-2313
Country	:	US
Telephone Number	:	770-975-1299
Fax Number	:	770-975-1361

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	07/08/2007

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