MEDICARE: LOCUST GROVE CLINIC, P.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	CHIROO6323	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GRP4337	OTHER	GA	MEDICARE GROUP

General Provider Information

NPI Number	:	1699964171
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOCUST GROVE CLINIC, P.C.

Provider Business Mailing Address
First Line	:	2648 HIGHWAY 42
Second Line	:
City	:	LOCUST GROVE
State	:	GA
Zip	:	30248-2519
Country	:	US
Telephone Number	:	770-898-0028
Fax Number	:	770-898-7987

Provider Business Practice Location Address
First Line	:	2648 HIGHWAY 42
Second Line	:
City	:	LOCUST GROVE
State	:	GA
Zip	:	30248-2519
Country	:	US
Telephone Number	:	770-898-0028
Fax Number	:	770-898-7987

Authorized Official
Title or Position	:	PRES
Name	:	DR. PETER J TULLY
Credential	:	D.C.
Telephone Number	:	770-898-0028

Provider Enumeration Date	:	10/19/2007
Last Update Date	:	10/19/2007

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