1033646567 NPI number — KIMBERLY ELAINE PERRA PTA

Table of content: KIMBERLY ELAINE PERRA PTA (NPI 1033646567)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033646567 NPI number — KIMBERLY ELAINE PERRA PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERRA
Provider First Name:
KIMBERLY
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1033646567
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
265 POCKET RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICKAMAUGA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30707-4732
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 PARK CITY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30741-3980
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-858-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2017

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

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

  • Identifier: 1468 . This is a "PHYSICAL THERAPIST ASSISTANT" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1468 . This is a "PHYSICAL THERAPIST ASSIST" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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