Provider Demographics
NPI:1780880302
Name:DECATUR NECK AND BACK
Entity type:Organization
Organization Name:DECATUR NECK AND BACK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:BANGUILAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-963-5585
Mailing Address - Street 1:960 HERRINGTON RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-7212
Mailing Address - Country:US
Mailing Address - Phone:770-963-5585
Mailing Address - Fax:770-682-7636
Practice Address - Street 1:960 HERRINGTON RD
Practice Address - Street 2:SUITE B
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-7212
Practice Address - Country:US
Practice Address - Phone:770-963-5585
Practice Address - Fax:770-682-7636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006452111NR0400X
GACHIR008031111NR0400X
GA016356207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCJMZMedicare ID - Type Unspecified