1255518478 NPI number — PEACHSTREET IMMEDIATE CARE CENTER

Table of content: (NPI 1255518478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255518478 NPI number — PEACHSTREET IMMEDIATE CARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACHSTREET IMMEDIATE CARE CENTER
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:
1255518478
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4426 AUSTELL RD
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:
30106-1844
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-398-5440
Provider Business Mailing Address Fax Number:
678-398-5442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4426 AUSTELL RD
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:
30106-1844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-398-5440
Provider Business Practice Location Address Fax Number:
678-398-5442
Provider Enumeration Date:
01/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
NGUYEN
Authorized Official First Name:
DIEM
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
678-398-5440

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com