Healthcare Provider Details

I. General information

NPI: 1386365567
Provider Name (Legal Business Name): KRISTOPHER NICHOLAS URBANOVITCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD # 508121
DECATUR GA
30033-4004
US

IV. Provider business mailing address

3018 KENTMERE DR
CUMMING GA
30040-1220
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax:
Mailing address:
  • Phone: 770-371-8030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number131
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number131
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: