Provider Demographics
NPI:1902572118
Name:PEREZ CABALLERO, GUSTAVO ANDRE (BS, DC, GTS)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ANDRE
Last Name:PEREZ CABALLERO
Suffix:
Gender:M
Credentials:BS, DC, GTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3360 STEVE REYNOLDS BLVD APT 2411
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4588
Mailing Address - Country:US
Mailing Address - Phone:470-421-1225
Mailing Address - Fax:
Practice Address - Street 1:1379 IRIS DR SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-1768
Practice Address - Country:US
Practice Address - Phone:404-964-4985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010551111N00000X, 111NS0005X, 111NX0800X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NX0800XChiropractic ProvidersChiropractorOrthopedic