1780067991 NPI number — STEVE BALLESTEROS

Table of content: STEVE BALLESTEROS (NPI 1780067991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780067991 NPI number — STEVE BALLESTEROS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALLESTEROS
Provider First Name:
STEVE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1780067991
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2206 CAMILLE DR
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31906-1002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-442-2249
Provider Business Mailing Address Fax Number:
762-208-4985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2206 CAMILLE DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31906-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-442-2249
Provider Business Practice Location Address Fax Number:
762-208-4985
Provider Enumeration Date:
07/07/2015

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: 332B00000X , with the licence number:  131812 , 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: 474359436 . This is a "TRICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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