1558846196 NPI number — LARRY JENKINS CACII, NCACII, B.S.

Table of content: LARRY JENKINS CACII, NCACII, B.S. (NPI 1558846196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558846196 NPI number — LARRY JENKINS CACII, NCACII, B.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENKINS
Provider First Name:
LARRY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CACII, NCACII, B.S.
Provider Gender Code:
M

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:
1558846196
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
41 FARMER ST STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWNAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30263-8672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-683-3150
Provider Business Mailing Address Fax Number:
770-683-3151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 PEACHTREE CT STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEACHTREE CITY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30269-4800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-719-1746
Provider Business Practice Location Address Fax Number:
770-716-2368
Provider Enumeration Date:
09/29/2018

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:  1684CACII , 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)