1437419769 NPI number — SHONTAVIA LATRICE ROBINSON B.S

Table of content: SHONTAVIA LATRICE ROBINSON B.S (NPI 1437419769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437419769 NPI number — SHONTAVIA LATRICE ROBINSON B.S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBINSON
Provider First Name:
SHONTAVIA
Provider Middle Name:
LATRICE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
B.S
Provider Gender Code:
M

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:
1437419769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6036
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31917-6036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-332-5028
Provider Business Mailing Address Fax Number:
888-317-2710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5803 MEMPHIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31907-2923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-332-5028
Provider Business Practice Location Address Fax Number:
888-317-2710
Provider Enumeration Date:
05/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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