1669551800 NPI number — TRACY LOPES PTA

Table of content: TRACY LOPES PTA (NPI 1669551800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669551800 NPI number — TRACY LOPES PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPES
Provider First Name:
TRACY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

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:
1669551800
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 518
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-631-8277
Provider Business Mailing Address Fax Number:
770-631-9403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 PROFESSIONAL DR # A
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30045-7698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-517-0839
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/06/2006

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: 225200000X , with the licence number:  PTA001971 , 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: PTA001971 . This is a "STATE LISC NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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