1437476868 NPI number — MRS. ECCLESIA LUCIANA GRANT LDO

Table of content: MRS. ECCLESIA LUCIANA GRANT LDO (NPI 1437476868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437476868 NPI number — MRS. ECCLESIA LUCIANA GRANT LDO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANT
Provider First Name:
ECCLESIA
Provider Middle Name:
LUCIANA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LDO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRANT
Provider Other First Name:
ECCLESIA
Provider Other Middle Name:
LUCIANA
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.D.O.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1437476868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
165 HIDDEN BROOK CT
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:
30349-4440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-432-1772
Provider Business Mailing Address Fax Number:
404-890-5574

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5534 OLD NATIONAL HWY
Provider Second Line Business Practice Location Address:
SUITES 100-B
Provider Business Practice Location Address City Name:
COLLEGE PARK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30349-3212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-432-1772
Provider Business Practice Location Address Fax Number:
404-890-5574
Provider Enumeration Date:
04/25/2010

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: 156FX1800X , with the licence number:  LDO 002273 , 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)





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