1588098529 NPI number — FUNDAMENTAL HEALTH GROUP, LLC

Table of content: (NPI 1588098529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588098529 NPI number — FUNDAMENTAL HEALTH GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNDAMENTAL HEALTH GROUP, 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:
BRIGHTSTAR OF NW ATLANTA
Provider Other Organization Name Type Code:
3
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:
1588098529
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 PEACHTREE ST NE
Provider Second Line Business Mailing Address:
SUITE 1210
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30308-2237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-856-7610
Provider Business Mailing Address Fax Number:
866-266-5030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 PEACHTREE ST NE
Provider Second Line Business Practice Location Address:
SUITE 1210
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30308-2237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-856-7610
Provider Business Practice Location Address Fax Number:
866-266-5030
Provider Enumeration Date:
08/27/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FRASER
Authorized Official First Name:
ADAM
Authorized Official Middle Name:
JACOB
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
404-856-7610

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 060-R-1213 . This is a "HOME CARE PROVIDER LICENSE - SKILLED NURSING, PERSONAL CARE, & COMPANION/SITTER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 563170 . This is a "JOINT COMMISSION ACCRED" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: SCSA095804 . This is a "CERTIFIED SENIOR ADVISOR" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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