Healthcare Provider Details

I. General information

NPI: 1720262363
Provider Name (Legal Business Name): BABYBOOMERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2053 STANTON RD
EAST POINT GA
30344-1311
US

IV. Provider business mailing address

2053 STANTON RD
EAST POINT GA
30344-1311
US

V. Phone/Fax

Practice location:
  • Phone: 404-768-2030
  • Fax:
Mailing address:
  • Phone: 404-768-2030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MS. RENATA JOHNSON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 678-779-9061