Basic Information
Provider Information | |||||||||
NPI: | 1003018714 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MATHIS | ||||||||
FirstName: | CJ | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CFA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MATHIS-CHANDLER | ||||||||
OtherFirstName: | CJ | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CFA | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 104 LAKESHORE DR | ||||||||
Address2: | SUITE B | ||||||||
City: | SAINT MARYS | ||||||||
State: | GA | ||||||||
PostalCode: | 315583803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9126731771 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 104 LAKESHORE DR | ||||||||
Address2: | SUITE B | ||||||||
City: | SAINT MARYS | ||||||||
State: | GA | ||||||||
PostalCode: | 315583803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9126731771 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/04/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X |   | GA | Y |   |   |   |   |
No ID Information.