MEDICARE: ROBERT LARGE

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	CHIRO09332	GA

General Provider Information

NPI Number	:	1750783924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT LARGE

Provider Business Mailing Address
First Line	:	3319 RIVER HEIGHTS XING SE
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-4860
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3565 PIEDMONT RD NE
Second Line	:	BUILDING 2 SUITE 310
City	:	ATLANTA
State	:	GA
Zip	:	30305-8202
Country	:	US
Telephone Number	:	404-352-8900
Fax Number	:

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

Provider Enumeration Date	:	09/19/2014
Last Update Date	:	09/19/2014

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