1770610941 NPI number — RESURGENS, LLC

Table of content: DR. KATHLEEN MARIE INMAN FUENTES MD (NPI 1275100091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770610941 NPI number — RESURGENS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RESURGENS, 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:
1770610941
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 21068
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-847-9999
Provider Business Mailing Address Fax Number:
404-531-8466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6001 PROFESSIONAL PKWY
Provider Second Line Business Practice Location Address:
SUITE 1040
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30134-5602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-949-7400
Provider Business Practice Location Address Fax Number:
770-942-1162
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SPRINGER
Authorized Official First Name:
VALERIE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
404-531-8615

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , 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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