1164655387 NPI number — LIFE POINT FAMILY COUNSELING CENTER

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 1164655387 NPI number — LIFE POINT FAMILY COUNSELING CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE POINT FAMILY COUNSELING CENTER
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:
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:
1164655387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1246A CONCORD RD SE STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMYRNA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30080-4360
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:
1246A CONCORD RD SE STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMYRNA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30080-4360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-689-6537
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WYNN
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-689-6537

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  LPC004071 , 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: 490053298E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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