1962887596 NPI number — ACADEMY ORTHOPEDICS LLC

Table of content: (NPI 1962887596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962887596 NPI number — ACADEMY ORTHOPEDICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACADEMY ORTHOPEDICS 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:
1962887596
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3929 CARTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUFORD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30518-1628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-271-9855
Provider Business Mailing Address Fax Number:
770-271-1118

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3929 CARTER RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUFORD
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-271-9855
Provider Business Practice Location Address Fax Number:
770-271-1118
Provider Enumeration Date:
07/24/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MORGAN
Authorized Official First Name:
PAM
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
770-271-9855

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  28421 , 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: 6472090002 . This is a "MEDICARE DME" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 300025973D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".