Healthcare Provider Details

I. General information

NPI: 1063103778
Provider Name (Legal Business Name): NSP1RE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5317 PEACHTREE BLVD GUARDIAN BUSINESS CENTER S306
CHAMBLEE GA
30341
US

IV. Provider business mailing address

5317 PEACHTREE BLVD S306
CHAMBLEE GA
30341
US

V. Phone/Fax

Practice location:
  • Phone: 678-671-0078
  • Fax: 888-948-2083
Mailing address:
  • Phone: 678-671-0078
  • Fax: 888-948-2083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LATORIA JACKAON
Title or Position: CEO
Credential:
Phone: 678-671-0078