1952480204 NPI number — MRS. SARAH LIQUORI HEATON PT

Table of content: MRS. SARAH LIQUORI HEATON PT (NPI 1952480204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952480204 NPI number — MRS. SARAH LIQUORI HEATON PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEATON
Provider First Name:
SARAH
Provider Middle Name:
LIQUORI
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LIQUORI
Provider Other First Name:
SARAH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1952480204
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 518
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30237-0518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-631-8277
Provider Business Mailing Address Fax Number:
770-631-9403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1720 PEACHTREE ST NW
Provider Second Line Business Practice Location Address:
SUITE 422
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30309-2449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-733-1936
Provider Business Practice Location Address Fax Number:
404-733-1940
Provider Enumeration Date:
11/06/2006

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: 225100000X , with the licence number:  PT007930 , 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)

  • Identifier: PT007930 . This is a "STATE LISC NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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