1770181588 NPI number — MR. LEONARD F FREEMAN III BS

Table of content: MR. LEONARD F FREEMAN III BS (NPI 1770181588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770181588 NPI number — MR. LEONARD F FREEMAN III BS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREEMAN
Provider First Name:
LEONARD
Provider Middle Name:
F
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
BS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FREEMAN
Provider Other First Name:
TREY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1770181588
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
146 REDFERN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT SIMONS ISLAND
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31522-2042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2175 PARKLAKE DR NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30345-2845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-496-7400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2020

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: 183500000X , with the licence number:  015734 , 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: 053190374 . This is a "STATE DRIVERS LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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