Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0400X | Rehabilitation Chiropractor | CHIR006452 | GA |
NPI | 1275738296 |
---|---|
Provider Name | Dr. Tony Banguilan |
First Address | Lawrenceville, GA 30044-7212 |
Second Address | Lawrenceville, GA 30044-7212 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2007 |
Last Update Date | 08/07/2007 |