1750426755 NPI number — DEKALB COMMUNITY SERVICE BOARD

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 1750426755 NPI number — DEKALB COMMUNITY SERVICE BOARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEKALB COMMUNITY SERVICE BOARD
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:
1750426755
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 WINN WAY FL 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30030-1707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-294-3836
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2129 LURAY CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUNWOODY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30338-5212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-452-7122
Provider Business Practice Location Address Fax Number:
770-452-7122
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VAN DER MERWE
Authorized Official First Name:
FABIO
Authorized Official Middle Name:
BRUNO
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
404-294-3836

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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