1679683015 NPI number — MRS. IRENE LEWIS BRUMFIELD RD, LD

Table of content: MRS. IRENE LEWIS BRUMFIELD RD, LD (NPI 1679683015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679683015 NPI number — MRS. IRENE LEWIS BRUMFIELD RD, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUMFIELD
Provider First Name:
IRENE
Provider Middle Name:
LEWIS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRUMFIELD
Provider Other First Name:
IRENE
Provider Other Middle Name:
SHARON
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1679683015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3636 PREAKNESS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30034-3338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-403-3035
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2669 CHURCH ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
EAST POINT
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30344-3115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-209-0113
Provider Business Practice Location Address Fax Number:
404-209-0285
Provider Enumeration Date:
08/30/2006

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: 133V00000X , with the licence number:  000465 , 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)





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