1194737809 NPI number — COTTON ANCILLARY SERVICES, LLC

Table of content: (NPI 1194737809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194737809 NPI number — COTTON ANCILLARY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COTTON ANCILLARY SERVICES, LLC
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:
6
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:
1194737809
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2862 JOHNSON FERRY RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30062-8342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-650-6672
Provider Business Mailing Address Fax Number:
770-650-6682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2862 JOHNSON FERRY RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30062-8342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-650-6672
Provider Business Practice Location Address Fax Number:
770-650-6682
Provider Enumeration Date:
08/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARDIN
Authorized Official First Name:
M.
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-650-6672

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4582219 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009913998 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000904879A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200803670 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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