1700996642 NPI number — LUANNE MARIA MACISAAC PT

Table of content: LUANNE MARIA MACISAAC PT (NPI 1700996642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700996642 NPI number — LUANNE MARIA MACISAAC PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACISAAC
Provider First Name:
LUANNE
Provider Middle Name:
MARIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1700996642
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6397 LEE HWY STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37421-4915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-238-7217
Provider Business Mailing Address Fax Number:
423-238-3473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7130 MOUNT ZION BLVD STE 9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30236-2566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-603-5660
Provider Business Practice Location Address Fax Number:
770-603-6779
Provider Enumeration Date:
08/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT013826 , 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)

  • Identifier: PT5430 . This is a "LICENSE#" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".