1639571532 NPI number — SOUTH ATLANTA MUA CENTER, LLC

Table of content: (NPI 1639571532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639571532 NPI number — SOUTH ATLANTA MUA CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH ATLANTA MUA 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:
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:
1639571532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1601
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHENIX CITY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36867
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-880-7568
Provider Business Mailing Address Fax Number:
866-837-9033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
541 FOREST PKWY
Provider Second Line Business Practice Location Address:
STE 14
Provider Business Practice Location Address City Name:
FOREST PARK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30297-6144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-880-7568
Provider Business Practice Location Address Fax Number:
866-837-9033
Provider Enumeration Date:
09/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
855-880-7568

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  031143 , 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)





Copyright © 2007-2026 www.npivalidator.com