1336525005 NPI number — 2801 FELTON AVENUE, L.P.

Table of content: BRAD KRELL PT, DPT, ATC (NPI 1922489814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336525005 NPI number — 2801 FELTON AVENUE, L.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
2801 FELTON AVENUE, L.P.
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:
1336525005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3000 OLD ALABAMA RD STE 119-403
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30022-5860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-282-4755
Provider Business Mailing Address Fax Number:
404-765-0547

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 FELTON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST POINT
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30344-3605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-767-7591
Provider Business Practice Location Address Fax Number:
404-765-0547
Provider Enumeration Date:
08/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DOUSTON
Authorized Official First Name:
DAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
404-282-4755

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , 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: 000140357A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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