1932502937 NPI number — CDR MANAGEMENT GROUP, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932502937 NPI number — CDR MANAGEMENT GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CDR MANAGEMENT GROUP, 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:
1932502937
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1145
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONLEY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30288-7017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-436-2226
Provider Business Mailing Address Fax Number:
770-217-4068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4151 MEMORIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-436-2226
Provider Business Practice Location Address Fax Number:
770-217-4068
Provider Enumeration Date:
10/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ROSS
Authorized Official First Name:
RONN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
404-436-2226

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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