Healthcare Provider Details

I. General information

NPI: 1306358668
Provider Name (Legal Business Name): RSS GARY NELSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11912 JONES BRIDGE RD STE B
ALPHARETTA GA
30005-4613
US

IV. Provider business mailing address

1050 TEXAN TRL STE 300
GRAPEVINE TX
76051-3759
US

V. Phone/Fax

Practice location:
  • Phone: 844-859-2525
  • Fax:
Mailing address:
  • Phone: 817-440-6060
  • Fax: 469-533-0476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SARA BROWN
Title or Position: DIRECTOR
Credential:
Phone: 817-440-6060