1760562706 NPI number — MRS. KIMLEY MAIENZA

Table of content: MRS. KIMLEY MAIENZA (NPI 1760562706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760562706 NPI number — MRS. KIMLEY MAIENZA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAIENZA
Provider First Name:
KIMLEY
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1760562706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1080 RIVER PLANTATION DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODSTOCK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30188-2387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-494-0999
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1827 POWERS FERRY RD SE
Provider Second Line Business Practice Location Address:
BLDG 24, SUITE 300
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30339-5621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-818-0070
Provider Business Practice Location Address Fax Number:
770-818-0068
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  000740 , 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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