1043242837 NPI number — MRS. TOMOE MARUTA FRYE LPTA

Table of content: MRS. TOMOE MARUTA FRYE LPTA (NPI 1043242837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043242837 NPI number — MRS. TOMOE MARUTA FRYE LPTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRYE
Provider First Name:
TOMOE
Provider Middle Name:
MARUTA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPTA
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:
1043242837
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1995 MEYERS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30045-3443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-466-5882
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5610 BERMUDA ROAD
Provider Second Line Business Practice Location Address:
STE. A
Provider Business Practice Location Address City Name:
STONE MOUNTAIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-684-3872
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/06/2006

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: 225200000X , with the licence number:  005059 , 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: 150477721 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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