1720962541 NPI number — PELLYNASH MEDICAL SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720962541 NPI number — PELLYNASH MEDICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PELLYNASH MEDICAL SERVICES
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:
1720962541
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
129 EWING WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DACULA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30019-5601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-437-2312
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
129 EWING WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DACULA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30019-5601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-437-2312
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/04/2025

Additional Information

Authorized Official

Authorized Official Last Name:
FONKIKA
Authorized Official First Name:
LOVELIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
404-437-2312

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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