Basic Information
Provider Information | |||||||||
NPI: | 1881245223 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | US DEPARTMENT OF VETERANS AFFAIRS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7675 LANIER VIEW RDG | ||||||||
Address2: |   | ||||||||
City: | CUMMING | ||||||||
State: | GA | ||||||||
PostalCode: | 300412162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708441909 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1670 CLAIRMONT RD | ||||||||
Address2: |   | ||||||||
City: | DECATUR | ||||||||
State: | GA | ||||||||
PostalCode: | 300334004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043216111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2019 | ||||||||
LastUpdateDate: | 09/26/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WINTER | ||||||||
AuthorizedOfficialFirstName: | KELLY | ||||||||
AuthorizedOfficialMiddleName: | DEAN | ||||||||
AuthorizedOfficialTitleorPosition: | PROSTHETIST | ||||||||
AuthorizedOfficialTelephone: | 4043216111 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0900X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Amputee |
No ID Information.