Provider Demographics
NPI:1871780114
Name:ROSWELL CHIROPRACTIS LIFE CENTER
Entity type:Organization
Organization Name:ROSWELL CHIROPRACTIS LIFE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:KRITZBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-788-1101
Mailing Address - Street 1:3505 SALEM RD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-4551
Mailing Address - Country:US
Mailing Address - Phone:770-788-1101
Mailing Address - Fax:770-788-0012
Practice Address - Street 1:3505 SALEM RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-4551
Practice Address - Country:US
Practice Address - Phone:770-788-1101
Practice Address - Fax:770-788-0012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4993111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3351Medicare UPIN
GA35ZCDFPMedicare UPIN