Healthcare Provider Details

I. General information

NPI: 1588786867
Provider Name (Legal Business Name): BRETT A GREENBLATT MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 W MEMORIAL DR
DALLAS GA
30132-4119
US

IV. Provider business mailing address

504 W MEMORIAL DR
DALLAS GA
30132-4119
US

V. Phone/Fax

Practice location:
  • Phone: 770-505-7190
  • Fax: 770-793-7413
Mailing address:
  • Phone: 770-505-7190
  • Fax: 770-793-7413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAUD003539
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: