Healthcare Provider Details

I. General information

NPI: 1770070237
Provider Name (Legal Business Name): WISTERIA D HENDRICKS DBA S&S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6065 LAKEVIEW OVERLOOK
LITHONIA GA
30038-3462
US

IV. Provider business mailing address

6065 LAKEVIEW OVERLOOK
LITHONIA GA
30038-3462
US

V. Phone/Fax

Practice location:
  • Phone: 678-691-9916
  • Fax: 404-304-5256
Mailing address:
  • Phone: 678-691-9916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MRS. WISTERIA D HENDRICKS
Title or Position: OWNER
Credential: BA, MBA, MHRM
Phone: 678-691-9916