Healthcare Provider Details

I. General information

NPI: 1134254758
Provider Name (Legal Business Name): LEWIS TIMOTHY KOLA D.MIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 CLAIRMONT RD
DECATUR GA
30033-3405
US

IV. Provider business mailing address

1814 CLAIRMONT RD
DECATUR GA
30033-3405
US

V. Phone/Fax

Practice location:
  • Phone: 404-636-1457
  • Fax: 404-636-7449
Mailing address:
  • Phone: 404-636-1457
  • Fax: 404-636-7449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberLPC003629
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: