1437669108 NPI number — MS. DEBORAH SUSAN LUPER MA, CAC1

Table of content: MS. DEBORAH SUSAN LUPER MA, CAC1 (NPI 1437669108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437669108 NPI number — MS. DEBORAH SUSAN LUPER MA, CAC1

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUPER
Provider First Name:
DEBORAH
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA, CAC1
Provider Gender Code:
F

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:
1437669108
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39 SHOALS FERRY ROAD SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-546-1129
Provider Business Mailing Address Fax Number:
770-383-3228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 FORREST AVENUE
Provider Second Line Business Practice Location Address:
A HEALING PLACE
Provider Business Practice Location Address City Name:
CARTERSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-383-3311
Provider Business Practice Location Address Fax Number:
770-383-3228
Provider Enumeration Date:
10/06/2017

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: 101YA0400X , with the licence number:  3433 , 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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