1598718512 NPI number — THE NEUROPSYCHIATRIC CLINIC OF ATLANTIS-VILLA RICA, P.C.

Table of content: (NPI 1598718512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598718512 NPI number — THE NEUROPSYCHIATRIC CLINIC OF ATLANTIS-VILLA RICA, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE NEUROPSYCHIATRIC CLINIC OF ATLANTIS-VILLA RICA, P.C.
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:
RANDY T. WARNER, M.D.
Provider Other Organization Name Type Code:
5
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:
1598718512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
690 DALLAS HIGHWAY
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
VILLA RICA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-840-8446
Provider Business Mailing Address Fax Number:
678-840-8482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
560 THORTON ROAD
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
LITHIA SPRINGS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-945-4211
Provider Business Practice Location Address Fax Number:
678-945-4221
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WARNER
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
OWNER/CEO
Authorized Official Telephone Number:
678-840-8446

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  053905 , 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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