Healthcare Provider Details

I. General information

NPI: 1003641663
Provider Name (Legal Business Name): LUCIUS SEPTIMIUS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 LANIER AVE W STE 200
FAYETTEVILLE GA
30214-7443
US

IV. Provider business mailing address

320 LANIER AVE W STE 200
FAYETTEVILLE GA
30214-7443
US

V. Phone/Fax

Practice location:
  • Phone: 678-545-9195
  • Fax:
Mailing address:
  • Phone: 678-545-9195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY A CLOWERS SR.
Title or Position: MANAGING MEMBER
Credential:
Phone: 678-545-9195