1790528354 NPI number — TWELVESTONE MEDICAL, INC

Table of content: (NPI 1790528354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790528354 NPI number — TWELVESTONE MEDICAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TWELVESTONE MEDICAL, 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:
1790528354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12369
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURFREESBORO
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37129-0048
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-278-3278
Provider Business Mailing Address Fax Number:
615-278-3355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3500 LOOP RD STE B4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCDONOUGH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30253-3133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-893-0012
Provider Business Practice Location Address Fax Number:
615-278-3355
Provider Enumeration Date:
06/13/2024

Additional Information

Authorized Official

Authorized Official Last Name:
REEVES
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
SHANE
Authorized Official Title or Position:
CEO, PRESIDENT, SECRETARY, AO
Authorized Official Telephone Number:
615-278-3146

Provider Taxonomy Codes

  • Taxonomy code: 3336H0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PHHH000083 . This is a "GA BOP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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