Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | CHIRO008042 | GA |
NPI | 1003933086 |
---|---|
Provider Name | Jared T Wiskind |
First Address | Roswell, GA 30076-3685 |
Second Address | Roswell, GA 30075-3867 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/03/2007 |
Last Update Date | 05/06/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
37-1538968 | TAX ID (01) | GA |