Healthcare Provider Details

I. General information

NPI: 1619032497
Provider Name (Legal Business Name): MICHAEL P KAVANAGH CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 VAN AALST BLVD
FORT MOORE GA
31905-2102
US

IV. Provider business mailing address

125 PERRYS MILL RD
PINE MOUNTAIN GA
31822-5112
US

V. Phone/Fax

Practice location:
  • Phone: 762-408-1467
  • Fax:
Mailing address:
  • Phone: 706-663-9715
  • Fax: 770-683-4872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number34
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number34
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: