1013938612 NPI number — FAMILY BRIDGE INTERNATIONAL INC

Table of content: (NPI 1013938612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013938612 NPI number — FAMILY BRIDGE INTERNATIONAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY BRIDGE INTERNATIONAL INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
N/A
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013938612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 MUNDYS MILL RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30238-5945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-231-7661
Provider Business Mailing Address Fax Number:
770-210-8497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 MUNDYS MILL RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30238-5945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-231-7661
Provider Business Practice Location Address Fax Number:
770-210-8497
Provider Enumeration Date:
07/21/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OKWANDU
Authorized Official First Name:
CORDELIA
Authorized Official Middle Name:
O
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
770-231-7661

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  031-R-0035 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)