1659722700 NPI number — MELISSA RUARK NP

Table of content: MELISSA RUARK NP (NPI 1659722700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659722700 NPI number — MELISSA RUARK NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUARK
Provider First Name:
MELISSA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1659722700
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 742936
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-2936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-219-8420
Provider Business Mailing Address Fax Number:
770-219-8440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
743 SPRING ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501-3715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-534-2020
Provider Business Practice Location Address Fax Number:
770-534-8025
Provider Enumeration Date:
06/29/2016

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: 363LF0000X , with the licence number:  RN142064 , 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)