1598253684 NPI number — COMFORT COMMUNITY CENTER, LLC

Table of content: (NPI 1598253684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598253684 NPI number — COMFORT COMMUNITY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMFORT COMMUNITY CENTER, 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:
6
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:
1598253684
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2440 SANDY PLAINS ROAD
Provider Second Line Business Mailing Address:
BLVD 21, SUITE 100
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-401-8743
Provider Business Mailing Address Fax Number:
770-675-3347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2440 SANDY PLAINS ROAD
Provider Second Line Business Practice Location Address:
BLVD 21, SUITE 100
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-401-8743
Provider Business Practice Location Address Fax Number:
770-675-3347
Provider Enumeration Date:
04/25/2018

Additional Information

Authorized Official

Authorized Official Last Name:
WOHIREN
Authorized Official First Name:
EMMANUEL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
678-581-1831

Provider Taxonomy Codes

  • Taxonomy code: 3140N1450X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 702748549N , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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