1205318029 NPI number — AT YOUR SERVICE ANESTHESIA, LLC

Table of content: (NPI 1205318029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205318029 NPI number — AT YOUR SERVICE ANESTHESIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AT YOUR SERVICE ANESTHESIA, 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:
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:
1205318029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 870822
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONE MOUNTAIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30087-0021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-395-6076
Provider Business Mailing Address Fax Number:
470-745-0716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2056 W PARK PLACE BLVD STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STONE MOUNTAIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30087-3537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-395-6076
Provider Business Practice Location Address Fax Number:
470-745-0716
Provider Enumeration Date:
08/29/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HOWARD
Authorized Official First Name:
SELWYNN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
470-395-6076

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com