Provider Demographics
NPI:1780092072
Name:OBALLE, FERNANDO
Entity type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:
Last Name:OBALLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 OLD ALABAMA RD
Mailing Address - Street 2:SUITE 119-317
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-5860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 OLD ALABAMA RD
Practice Address - Street 2:SUITE 119-317
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-5860
Practice Address - Country:US
Practice Address - Phone:678-736-1635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO09060111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor