1295290450 NPI number — GEORGIA PALLIATIVE CARE SERVICES LLC

Table of content: (NPI 1295290450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295290450 NPI number — GEORGIA PALLIATIVE CARE SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA PALLIATIVE CARE SERVICES LLC
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:
1295290450
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 N 2100 W STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84116-4741
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-924-8571
Provider Business Mailing Address Fax Number:
801-883-8044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2849 PACES FERRY RD SE STE 380
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30339-3769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-737-0300
Provider Business Practice Location Address Fax Number:
801-883-8044
Provider Enumeration Date:
02/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
MARK
Authorized Official Middle Name:
L
Authorized Official Title or Position:
NATIONAL DIRECTOR OF PHYSICIAN SER.
Authorized Official Telephone Number:
801-924-4992

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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