Healthcare Provider Details

I. General information

NPI: 1386195774
Provider Name (Legal Business Name): MR. SCOTT KERNS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 HIGHLAND AVE NE APT 1156
ATLANTA GA
30312-1391
US

IV. Provider business mailing address

433 HIGHLAND AVE NE APT 1156
ATLANTA GA
30312-1391
US

V. Phone/Fax

Practice location:
  • Phone: 678-428-1383
  • Fax:
Mailing address:
  • Phone: 678-428-1383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: