1467572321 NPI number — BETHEL GROUP OF GEORGIA INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467572321 NPI number — BETHEL GROUP OF GEORGIA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BETHEL GROUP OF GEORGIA INC
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:
1467572321
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2870 PEACHTREE RD NW
Provider Second Line Business Mailing Address:
SUITE 919
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30305-2918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-735-9844
Provider Business Mailing Address Fax Number:
404-355-4669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2870 PEACHTREE RD NW
Provider Second Line Business Practice Location Address:
SUITE 919
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30305-2918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-735-9844
Provider Business Practice Location Address Fax Number:
404-355-4669
Provider Enumeration Date:
04/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BACALLAO
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
JUAN
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
404-735-9844

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  139625LGB , 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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