Provider Demographics
NPI:1144311408
Name:HERITAGE CHIROPRACTIC CLINC INC
Entity type:Organization
Organization Name:HERITAGE CHIROPRACTIC CLINC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:ALEN
Authorized Official - Last Name:SANDELS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:770-979-2731
Mailing Address - Street 1:2407 LENORA CHURCH ROAD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:60078-6916
Mailing Address - Country:US
Mailing Address - Phone:770-979-2731
Mailing Address - Fax:770-972-2978
Practice Address - Street 1:2407 LENORA CHURCH ROAD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6916
Practice Address - Country:US
Practice Address - Phone:770-979-2731
Practice Address - Fax:770-972-2978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR0001971111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T97820Medicare UPIN