1467629881 NPI number — MR. WESLEY GREGORY MITCHELL JR. MSA,CSA

Table of content: MR. WESLEY GREGORY MITCHELL JR. MSA,CSA (NPI 1467629881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467629881 NPI number — MR. WESLEY GREGORY MITCHELL JR. MSA,CSA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHELL
Provider First Name:
WESLEY
Provider Middle Name:
GREGORY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MSA,CSA
Provider Gender Code:
M

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:
1467629881
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11340 LAKEFIELD DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
JOHNS CREEK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30097-1714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-771-4728
Provider Business Mailing Address Fax Number:
404-393-9515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11340 LAKEFIELD DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
JOHNS CREEK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30097-1714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-629-8289
Provider Business Practice Location Address Fax Number:
404-393-9515
Provider Enumeration Date:
05/14/2008

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: 363AS0400X , with the licence number:  3245 , 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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