1063056760 NPI number — KELLY W GLADDEN RRT, RPSGT, CCSH RST

Table of content: KELLY W GLADDEN RRT, RPSGT, CCSH RST (NPI 1063056760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063056760 NPI number — KELLY W GLADDEN RRT, RPSGT, CCSH RST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLADDEN
Provider First Name:
KELLY
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RRT, RPSGT, CCSH RST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALKLEY
Provider Other First Name:
KELLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063056760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
575 CRICKLEWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUWANEE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30024-8544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-849-6943
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2540 WINDY HILL RD SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30067-8605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-849-6943
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/05/2019

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: 246Z00000X , with the licence number:  305 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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