1760827190 NPI number — DISTINCTIVELY YOURS OF GEORGIA, INC

Table of content: (NPI 1760827190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760827190 NPI number — DISTINCTIVELY YOURS OF GEORGIA, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DISTINCTIVELY YOURS OF GEORGIA, 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:
1760827190
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8435 MAGNOLIA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30238-3132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-479-9462
Provider Business Mailing Address Fax Number:
770-507-9075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8435 MAGNOLIA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30238-3132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-507-0125
Provider Business Practice Location Address Fax Number:
770-507-9075
Provider Enumeration Date:
04/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WARNER
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
N
Authorized Official Title or Position:
DIRECTOR/CEO
Authorized Official Telephone Number:
770-507-0125

Provider Taxonomy Codes

  • Taxonomy code: 3104A0630X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003108953B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003108953E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003108953D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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