1811362684 NPI number — LARA ALBANESE, LLC

Table of content: (NPI 1811362684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811362684 NPI number — LARA ALBANESE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARA ALBANESE, LLC
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:
1811362684
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4343 SHALLOWFORD RD. SUITE C2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-346-1233
Provider Business Mailing Address Fax Number:
770-993-9800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4343 SHALLOWFORD RD. SUITE C2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-346-1233
Provider Business Practice Location Address Fax Number:
770-993-9800
Provider Enumeration Date:
12/04/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ALBANESE
Authorized Official First Name:
LARA
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
LPC
Authorized Official Telephone Number:
678-346-1233

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , 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: 003148245A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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