1780107474 NPI number — LARISSA ALEKSANDROVNA MELNIK PA

Table of content: LARISSA ALEKSANDROVNA MELNIK PA (NPI 1780107474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780107474 NPI number — LARISSA ALEKSANDROVNA MELNIK PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELNIK
Provider First Name:
LARISSA
Provider Middle Name:
ALEKSANDROVNA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1780107474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 PEACHTREE INDUSTRIAL BLVD STE 4101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUWANEE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30024-4542
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-831-5525
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5610 BETHELVIEW RD STE 500A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUMMING
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30040-7530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-205-2804
Provider Business Practice Location Address Fax Number:
770-205-2854
Provider Enumeration Date:
07/25/2017

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: 363A00000X , with the licence number:  008409 , 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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