1548353261 NPI number — MONFORT COMPOUNDING CENTER

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 1548353261 NPI number — MONFORT COMPOUNDING CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONFORT COMPOUNDING 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:
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:
1548353261
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:
PO BOX 821
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30046-0821
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-963-2813
Provider Business Mailing Address Fax Number:
770-963-0166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
470 NORTH CLAYTON STREET
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-963-2813
Provider Business Practice Location Address Fax Number:
770-962-0166
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GORMAN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
CARTER
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-963-2813

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  8344 , 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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