1457425159 NPI number — LAKESHORE TUBAL REVERSAL CENTER

Table of content: (NPI 1457425159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457425159 NPI number — LAKESHORE TUBAL REVERSAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESHORE TUBAL REVERSAL CENTER
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:
1457425159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2320 LIMESTONE PARKWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-588-5594
Provider Business Mailing Address Fax Number:
770-531-0053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2320 LIMESTONE PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-588-5594
Provider Business Practice Location Address Fax Number:
770-531-0053
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BATES
Authorized Official First Name:
CECILIA
Authorized Official Middle Name:
ASHLEIGH
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
770-531-1181

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  GA LIC 022231 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QA1903X , with the licence number: DEA AG5691452 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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