1881107118 NPI number — WISBA HOME CARE AND PROFESSIONAL CAREER CENTER LLC

Table of content: DR. MATTHEW JACOB BOYER M.D., PH.D. (NPI 1043586142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881107118 NPI number — WISBA HOME CARE AND PROFESSIONAL CAREER CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WISBA HOME CARE AND PROFESSIONAL CAREER CENTER 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:
1881107118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1915
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNESAW
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30156-8915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-696-9905
Provider Business Mailing Address Fax Number:
800-410-2504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2220 ATLANTA RD SE STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMYRNA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30080-1541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-413-9066
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/08/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BASTIA
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER ADMINISTRATOR CEO
Authorized Official Telephone Number:
678-425-4030

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  033-R-1532 , 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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