Healthcare Provider Details

I. General information

NPI: 1821423112
Provider Name (Legal Business Name): ENSPHERE RESOURCES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 RIVERSIDE DR SUITE B275
MACON GA
31210-2550
US

IV. Provider business mailing address

403 LAKEVIEW PL
MACON GA
31211-6127
US

V. Phone/Fax

Practice location:
  • Phone: 478-787-9153
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM AGUDELO
Title or Position: OWNDER
Credential:
Phone: 478-787-9153