Healthcare Provider Details

I. General information

NPI: 1871131813
Provider Name (Legal Business Name): RAVIK FOUNDATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2019
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1343 BUSINESS CENTER DR SW STE B
CONYERS GA
30094-6609
US

IV. Provider business mailing address

4715 CLEVELAND RD
LITHONIA GA
30038-2610
US

V. Phone/Fax

Practice location:
  • Phone: 855-587-2845
  • Fax:
Mailing address:
  • Phone: 678-462-2577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: JARED JEFFRIES
Title or Position: OWNER
Credential:
Phone: 678-462-2577