1003845967 NPI number — THE NATHANIEL WATSON, JR. MEMORIAL FOUNDATION, INC

Table of content: (NPI 1003845967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003845967 NPI number — THE NATHANIEL WATSON, JR. MEMORIAL FOUNDATION, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE NATHANIEL WATSON, JR. MEMORIAL FOUNDATION, 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:
BALM OF GILEAD MEDICAL SERVICES
Provider Other Organization Name Type Code:
3
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:
1003845967
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
506 CALGARY GLEN DRIVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30168-7284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-732-9196
Provider Business Mailing Address Fax Number:
770-770-0739

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 CALGARY GLEN DRIVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30168-7284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-770-9196
Provider Business Practice Location Address Fax Number:
770-732-0739
Provider Enumeration Date:
07/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WATSON-BAXTER
Authorized Official First Name:
VALERIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
770-693-8852

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3140N1450X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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