Healthcare Provider Details

I. General information

NPI: 1780920900
Provider Name (Legal Business Name): JUSTIN SPEARS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2012
Last Update Date: 12/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2037 MESA DR SE
ATLANTA GA
30316-4915
US

IV. Provider business mailing address

2037 MESA DR SE
ATLANTA GA
30316-4915
US

V. Phone/Fax

Practice location:
  • Phone: 404-713-9382
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: