Healthcare Provider Details

I. General information

NPI: 1043668254
Provider Name (Legal Business Name): CHARLES GAINES JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 NORTHWINDS PKWY
ALPHARETTA GA
30009-2280
US

IV. Provider business mailing address

2655 NORTHWINDS PKWY
ALPHARETTA GA
30009-2280
US

V. Phone/Fax

Practice location:
  • Phone: 678-690-8340
  • Fax:
Mailing address:
  • Phone: 678-690-8332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number169444
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC003150
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: