1710142955 NPI number — PREVENTIVE MEDICINE & CHELATION THERAPY INC

Table of content: (NPI 1710142955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710142955 NPI number — PREVENTIVE MEDICINE & CHELATION THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREVENTIVE MEDICINE & CHELATION THERAPY INC
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:
1710142955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
148 COBB PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RINGGOLD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30736-8566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-891-1200
Provider Business Mailing Address Fax Number:
706-891-1202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
148 COBB PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RINGGOLD
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30736-8566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-891-1200
Provider Business Practice Location Address Fax Number:
706-891-1202
Provider Enumeration Date:
07/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BURKICH
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
706-891-1200

Provider Taxonomy Codes

  • Taxonomy code: 305S00000X , with the licence number:  MD046372 , 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: 511G70685 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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