1770709628 NPI number — MR. CHARLES TRUMAN COLBERT JR. C.S.T./C.F.A.

Table of content: MR. CHARLES TRUMAN COLBERT JR. C.S.T./C.F.A. (NPI 1770709628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770709628 NPI number — MR. CHARLES TRUMAN COLBERT JR. C.S.T./C.F.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLBERT
Provider First Name:
CHARLES
Provider Middle Name:
TRUMAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
C.S.T./C.F.A.
Provider Gender Code:
M

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:
1770709628
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
334 DYLAN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCDONOUGH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30252-6186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-914-1517
Provider Business Mailing Address Fax Number:
770-991-1155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6525 PROFESSIONAL PL
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
RIVERDALE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30274-2519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-991-1150
Provider Business Practice Location Address Fax Number:
770-991-1155
Provider Enumeration Date:
04/18/2007

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: 246ZS0410X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246ZC0007X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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