1083816243 NPI number — MR. STACEY ALLEN HATHCOCK DPT

Table of content: MR. STACEY ALLEN HATHCOCK DPT (NPI 1083816243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083816243 NPI number — MR. STACEY ALLEN HATHCOCK DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HATHCOCK
Provider First Name:
STACEY
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

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:
1083816243
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
274 EASTWOOD LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORDELE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31015-5933
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-271-3760
Provider Business Mailing Address Fax Number:
229-271-4612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
307 THIRD AVENUE
Provider Second Line Business Practice Location Address:
CRISP REGIONAL THERAPIES
Provider Business Practice Location Address City Name:
CORDELE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-271-4612
Provider Business Practice Location Address Fax Number:
229-271-4616
Provider Enumeration Date:
06/01/2007

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:  5830 , 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: 474753088A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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