1942498050 NPI number — THE BREAST CARE TEAM , PC

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 1942498050 NPI number — THE BREAST CARE TEAM , PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE BREAST CARE TEAM , PC
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:
1942498050
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 RIVERSTONE TER
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30114-1702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-704-6977
Provider Business Mailing Address Fax Number:
770-704-6169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 RIVERSTONE TER
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30114-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-704-6977
Provider Business Practice Location Address Fax Number:
770-704-6169
Provider Enumeration Date:
10/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
ANITA
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
770-704-6977

Provider Taxonomy Codes

  • Taxonomy code: 2086X0206X , with the licence number:  053464 , 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)





Copyright © 2007-2025 www.npivalidator.com