1518417641 NPI number — LARA MILLIKAN RANIC ACNPC-AG

Table of content: LARA MILLIKAN RANIC ACNPC-AG (NPI 1518417641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518417641 NPI number — LARA MILLIKAN RANIC ACNPC-AG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLIKAN RANIC
Provider First Name:
LARA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ACNPC-AG
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILLIKAN
Provider Other First Name:
LARA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518417641
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
230 PIONEER TRAIL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARTERSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-841-2099
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 TURNER MCCALL BLVD SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROME
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-509-3430
Provider Business Practice Location Address Fax Number:
706-291-2147
Provider Enumeration Date:
10/13/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  RN203833 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: RN203833 , 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)