Healthcare Provider Details

I. General information

NPI: 1871556464
Provider Name (Legal Business Name): LEE BALOS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 12/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 AUSTELL RD
AUSTELL GA
30106
US

IV. Provider business mailing address

PO BOX 155
AUSTELL GA
30168-1002
US

V. Phone/Fax

Practice location:
  • Phone: 770-732-3649
  • Fax: 770-732-3648
Mailing address:
  • Phone: 770-732-3649
  • Fax: 770-732-3648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN108726
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: