1316456825 NPI number — CHILDREN'S HEALTHCARE OF ATLANTA AT SCOTTISH RITE

Table of content: (NPI 1316456825)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316456825 NPI number — CHILDREN'S HEALTHCARE OF ATLANTA AT SCOTTISH RITE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDREN'S HEALTHCARE OF ATLANTA AT SCOTTISH RITE
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:
ORTHOTICS AND PROSTHETICS AT TOWN CENTER
Provider Other Organization Name Type Code:
3
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:
1316456825
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1575 NORTHEAST EXPY NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKHAVEN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30329-2401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-785-7876
Provider Business Mailing Address Fax Number:
404-785-7932

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
605 BIG SHANTY ROAD, NW
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
KENNESAW
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30144-3646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-785-3229
Provider Business Practice Location Address Fax Number:
404-785-5690
Provider Enumeration Date:
09/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
CODY
Authorized Official First Name:
LOUETTA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER, PROVIDER ENROLLMENT
Authorized Official Telephone Number:
404-785-7876

Provider Taxonomy Codes

  • Taxonomy code: 273Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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