Healthcare Provider Details

I. General information

NPI: 1629381876
Provider Name (Legal Business Name): RAVEN KAE BELMONTE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4484 PEACHTREE RD NE
ATLANTA GA
30319
US

IV. Provider business mailing address

111 RYAN WAY SE
SMYRNA GA
30080-8258
US

V. Phone/Fax

Practice location:
  • Phone: 404-261-1441
  • Fax:
Mailing address:
  • Phone: 919-868-0943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number2000003701
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: