1528103512 NPI number — DEKALB COMMUNITY SERVICE BOARD

Table of content: (NPI 1528103512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528103512 NPI number — DEKALB COMMUNITY SERVICE BOARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEKALB COMMUNITY SERVICE BOARD
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:
1528103512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/24/2020
NPI Reactivation Date:
05/01/2020

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
445 WINN WAY FL 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30030-1707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-294-3836
Provider Business Mailing Address Fax Number:
770-451-8018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3807 CLAIRMONT ROAD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMBLEE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-457-5867
Provider Business Practice Location Address Fax Number:
770-451-8018
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VAN DER MERWE
Authorized Official First Name:
FABIO
Authorized Official Middle Name:
BRUNO
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
404-294-3836

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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