Healthcare Provider Details

I. General information

NPI: 1093489817
Provider Name (Legal Business Name): MR. KEVIN CASSEDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

4151 OLD LINCOLNTON RD
APPLING GA
30802-4116
US

V. Phone/Fax

Practice location:
  • Phone: 706-294-6545
  • Fax:
Mailing address:
  • Phone: 706-294-6545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0800X
TaxonomyNeuroscience Registered Nurse
License NumberRN147826
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: