Healthcare Provider Details

I. General information

NPI: 1205900909
Provider Name (Legal Business Name): KENNETH CRAIG STALLINGS L..O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 BLUE RIDGE DR
BLUE RIDGE GA
30513-3245
US

IV. Provider business mailing address

270 GUNITE CIR #9251
ELLIJAY GA
30540-6453
US

V. Phone/Fax

Practice location:
  • Phone: 706-632-0384
  • Fax:
Mailing address:
  • Phone: 706-669-2386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number00013
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: