1053443374 NPI number — MRS. DONNA BING MANTOOTH L.P.C.

Table of content: MRS. DONNA BING MANTOOTH L.P.C. (NPI 1053443374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053443374 NPI number — MRS. DONNA BING MANTOOTH L.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANTOOTH
Provider First Name:
DONNA
Provider Middle Name:
BING
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
L.P.C.
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:
1053443374
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2722 BLACKS BLUFF RD SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30161-4337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-295-4809
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 INTERNATIONAL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ADAIRSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-295-2974
Provider Business Practice Location Address Fax Number:
770-773-3655
Provider Enumeration Date:
03/12/2007

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: 101YP2500X , with the licence number:  3364 , 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)





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