Healthcare Provider Details

I. General information

NPI: 1285446229
Provider Name (Legal Business Name): TAISEI CHIBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 EXECUTIVE PARK E
ATLANTA GA
30329
US

IV. Provider business mailing address

234 LINCOLN COURT AVE NE
BROOKHAVEN GA
30329-1815
US

V. Phone/Fax

Practice location:
  • Phone: 803-477-4339
  • Fax:
Mailing address:
  • Phone: 803-477-4339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: