1275868556 NPI number — ATLAS SUPPORTS

Table of content: ANNA LILY WONG PT, DPT (NPI 1205502564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275868556 NPI number — ATLAS SUPPORTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATLAS SUPPORTS
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:
1275868556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 SALUDA SHORES CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29070-7235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-582-9003
Provider Business Mailing Address Fax Number:
803-234-2927

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 SALUDA SHORES CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29070-7235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-582-9003
Provider Business Practice Location Address Fax Number:
803-234-2927
Provider Enumeration Date:
10/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
CHRISTIAN
Authorized Official Middle Name:
ATLAS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
803-582-9003

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-05-2205 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: WP8953 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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