Healthcare Provider Details

I. General information

NPI: 1700542644
Provider Name (Legal Business Name): DERRICK SAMS CPT CES PN1
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2021
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4775 LONGCOURT DR SE
ATLANTA GA
30339-1697
US

IV. Provider business mailing address

4775 LONGCOURT DR SE
ATLANTA GA
30339-1697
US

V. Phone/Fax

Practice location:
  • Phone: 678-907-0063
  • Fax:
Mailing address:
  • Phone: 678-907-0063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: