1598269714 NPI number — DWAYNE A LAY LLC

Table of content: (NPI 1598269714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598269714 NPI number — DWAYNE A LAY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DWAYNE A LAY LLC
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:
1598269714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10515 BELLS FERRY RD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30114-4242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-765-5828
Provider Business Mailing Address Fax Number:
678-388-0977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10515 BELLS FERRY RD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30114-4242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-765-5828
Provider Business Practice Location Address Fax Number:
678-388-0977
Provider Enumeration Date:
03/21/2018

Additional Information

Authorized Official

Authorized Official Last Name:
LAY
Authorized Official First Name:
DWAYNE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
770-765-5828

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  POD001230 , 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)

  • Identifier: 1598269714 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598269714 . This is a "TRANS AMERICA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598269714 . This is a "UNITED OF OMAHA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598269714 . This is a "ANTHEM OF GEORGIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598269714 . This is a "CHAMPVA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598269714 . This is a "GHI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598269714 . This is a "UNITEDHEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598269714 . This is a "CIGNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598269714 . This is a "TRICARE EAST/LIFE/PRIME" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598269714 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1598269714 . This is a "HUMANA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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