1740491257 NPI number — MARIETTA HEALTHCARE ASSOCIATES, LLC

Table of content: (NPI 1740491257)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740491257 NPI number — MARIETTA HEALTHCARE ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIETTA HEALTHCARE ASSOCIATES, 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:
SOUTHERN HEALTHCARE ASSOCIATES
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:
1740491257
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6881
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30065-0881
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-792-0927
Provider Business Mailing Address Fax Number:
770-792-7893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2759 DELK RD SE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30067-8847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-792-0927
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MEDRANO
Authorized Official First Name:
NELSON
Authorized Official Middle Name:
E
Authorized Official Title or Position:
MANAGING MEMBER OF LLC
Authorized Official Telephone Number:
770-792-0927

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  7142 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 111N00000X , with the licence number: 8031 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207R00000X , with the licence number: 022067 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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