Healthcare Provider Details

I. General information

NPI: 1497265003
Provider Name (Legal Business Name): MRS. DORCAS OHAERI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 RED HAWK WAY
DALLAS GA
30132-1149
US

IV. Provider business mailing address

4921 TRAIL RIDGE PL
DOUGLASVILLE GA
30134-8055
US

V. Phone/Fax

Practice location:
  • Phone: 561-801-3148
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: