MEDICARE: SUWANEE CHIROPRACTIC, 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	CHIR008941	GA

General Provider Information

NPI Number	:	1841531688
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUWANEE CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	2790 LAWRENCEVILLE SUWANEE RD
Second Line	:	SUITE 155
City	:	SUWANEE
State	:	GA
Zip	:	30024-2671
Country	:	US
Telephone Number	:	770-932-2014
Fax Number	:	770-932-2058

Provider Business Practice Location Address
First Line	:	2790 LAWRENCEVILLE SUWANEE RD
Second Line	:	SUITE 155
City	:	SUWANEE
State	:	GA
Zip	:	30024-2671
Country	:	US
Telephone Number	:	770-932-2014
Fax Number	:	770-932-2058

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	DR. JAY LEE
Credential	:	D.C.
Telephone Number	:	770-932-2014

Provider Enumeration Date	:	03/04/2013
Last Update Date	:	03/12/2013

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