Healthcare Provider Details

I. General information

NPI: 1366612491
Provider Name (Legal Business Name): SANDI J. STEPHENS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 W PONCE DE LEON AVE SUITE 7
DECATUR GA
30030-2458
US

IV. Provider business mailing address

250 NORWOOD AVE NE
ATLANTA GA
30317-1248
US

V. Phone/Fax

Practice location:
  • Phone: 404-964-1072
  • Fax:
Mailing address:
  • Phone: 404-964-1072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number004092
License Number StateGA

VIII. Authorized Official

Name: SANDI JACQUELYN STEPHENS
Title or Position: PRESIDENT
Credential:
Phone: 404-964-1072