Healthcare Provider Details

I. General information

NPI: 1457390643
Provider Name (Legal Business Name): THOMAS OBERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FREEDOM WAY
AUGUSTA GA
30904-6258
US

IV. Provider business mailing address

PO BOX 305 405 PINE STREET
GRANITEVILLE SC
29829-0305
US

V. Phone/Fax

Practice location:
  • Phone: 706-731-0188
  • Fax: 706-731-7165
Mailing address:
  • Phone: 706-733-0188
  • Fax: 706-731-7165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA000251
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: