Healthcare Provider Details

I. General information

NPI: 1043071814
Provider Name (Legal Business Name): MR. THOMAS LAMONT RUFFIN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 LAKELAND CT
AUGUSTA GA
30906-9215
US

IV. Provider business mailing address

12428 MAYS QUARTER RD
WOODBRIDGE VA
22192-5461
US

V. Phone/Fax

Practice location:
  • Phone: 706-204-9112
  • Fax:
Mailing address:
  • Phone: 571-552-2756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: