1255372041 NPI number — VANITCHA R PINTAVORN

Table of content: (NPI 1255372041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255372041 NPI number — VANITCHA R PINTAVORN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VANITCHA R PINTAVORN
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:
1255372041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
418 TOWN PARK BLVD
Provider Second Line Business Mailing Address:
STE 1A
Provider Business Mailing Address City Name:
EVANS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30809-3090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-650-1662
Provider Business Mailing Address Fax Number:
706-854-2131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
418 TOWN PARK BLVD
Provider Second Line Business Practice Location Address:
STE 1A
Provider Business Practice Location Address City Name:
EVANS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30809-3090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-650-1662
Provider Business Practice Location Address Fax Number:
706-854-2131
Provider Enumeration Date:
06/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PINTAVORN
Authorized Official First Name:
VANITCHA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
706-650-1662

Provider Taxonomy Codes

  • Taxonomy code: 207KA0200X , with the licence number:  048291 , 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: G48291 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52837117 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000894154D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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