Healthcare Provider Details

I. General information

NPI: 1700438587
Provider Name (Legal Business Name): EVELYN RAY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12570 LAKESIDE PKWY
FAYETTEVILLE GA
30215-4002
US

IV. Provider business mailing address

12570 LAKESIDE PKWY
FAYETTEVILLE GA
30215-4002
US

V. Phone/Fax

Practice location:
  • Phone: 404-946-9949
  • Fax:
Mailing address:
  • Phone: 404-946-9949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: TAMI WILLIAMS
Title or Position: OWNER
Credential:
Phone: 404-956-9949