1861662892 NPI number — JKP BALANCE & HEARING CENTER, LLC

Table of content: (NPI 1861662892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861662892 NPI number — JKP BALANCE & HEARING CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JKP BALANCE & HEARING CENTER, LLC
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:
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:
1861662892
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1270 CAROLINE ST NE
Provider Second Line Business Mailing Address:
SUITE D120-355
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30307-2758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
465 WINN WAY
Provider Second Line Business Practice Location Address:
SUITE 231
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30030-1753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-484-6305
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
POWELL
Authorized Official First Name:
TYSHA
Authorized Official Middle Name:
MOANA
Authorized Official Title or Position:
AUDIOLOGIST
Authorized Official Telephone Number:
404-484-6305

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  AUD003621 , 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)