1346756129 NPI number — LIFEBOAT MEDICAL ASSOCIATES 2, LLC

Table of content: (NPI 1346756129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346756129 NPI number — LIFEBOAT MEDICAL ASSOCIATES 2, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFEBOAT MEDICAL ASSOCIATES 2, 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:
1346756129
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 468329
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31146-8329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-943-0205
Provider Business Mailing Address Fax Number:
404-943-0209

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 GEORGIAN PARK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEACHTREE CITY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30269-6972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-631-4873
Provider Business Practice Location Address Fax Number:
770-631-0684
Provider Enumeration Date:
12/15/2017

Additional Information

Authorized Official

Authorized Official Last Name:
DEPP
Authorized Official First Name:
SHELLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
PAYER RELATIONS LIAISON
Authorized Official Telephone Number:
770-579-2626

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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