1790832566 NPI number — THERAPEUTIC DYNAMICS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790832566 NPI number — THERAPEUTIC DYNAMICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERAPEUTIC DYNAMICS
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:
1790832566
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2557 COLLINS PORT CV
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:
30024-2787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-232-7100
Provider Business Mailing Address Fax Number:
770-232-7198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1810 PEACHTREE INDUSTRIAL BLVD
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30097-8180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-232-7100
Provider Business Practice Location Address Fax Number:
770-232-7198
Provider Enumeration Date:
01/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PRESTON
Authorized Official First Name:
JON
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-232-7100

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT006667 , 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: 9406564 . This is a "PHCS PIN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52068657-004 . This is a "BCBSGA PPO PIN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 5675691 . This is a "FIRST HEALTH PIN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 681643 . This is a "ACN PIN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 7480721 . This is a "AETNA PPO POS PIN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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