1720395270 NPI number — SERVING ONE OF US

Table of content: (NPI 1720395270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720395270 NPI number — SERVING ONE OF US

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERVING ONE OF US
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:
1720395270
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1544 WELLBORN RD
Provider Second Line Business Mailing Address:
#3
Provider Business Mailing Address City Name:
LITHONIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30058-5492
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-428-2749
Provider Business Mailing Address Fax Number:
770-786-0499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1544 WELLBORN RD
Provider Second Line Business Practice Location Address:
#3
Provider Business Practice Location Address City Name:
LITHONIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30058-5492
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-428-2749
Provider Business Practice Location Address Fax Number:
770-786-0499
Provider Enumeration Date:
09/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WORTHY
Authorized Official First Name:
SHIRLEY
Authorized Official Middle Name:
WALKER
Authorized Official Title or Position:
OWNER/DIRECTOR/ADMINISTRATOR
Authorized Official Telephone Number:
404-428-2749

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , with the licence number:  600242281A , 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: 600242281A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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