1538609888 NPI number — BEPROACTIVE FOUNDATION, INC

Table of content: (NPI 1538609888)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538609888 NPI number — BEPROACTIVE FOUNDATION, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEPROACTIVE FOUNDATION, INC
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:
1538609888
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1830 WATER PL SE
Provider Second Line Business Mailing Address:
STE #220
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30339-7407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-319-7468
Provider Business Mailing Address Fax Number:
866-416-1767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1830 WATER PL SE
Provider Second Line Business Practice Location Address:
STE #220
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30339-7407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-319-7468
Provider Business Practice Location Address Fax Number:
866-416-1767
Provider Enumeration Date:
03/06/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LEWIS
Authorized Official First Name:
RJ
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
770-319-7468

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251V00000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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