Healthcare Provider Details

I. General information

NPI: 1689328304
Provider Name (Legal Business Name): MS. INDIA ADSIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 STEVEN DR APT 10204
MACON GA
31210-5877
US

IV. Provider business mailing address

159 STEVEN DR APT 10204
MACON GA
31210-5877
US

V. Phone/Fax

Practice location:
  • Phone: 478-284-8229
  • Fax:
Mailing address:
  • Phone: 478-284-8229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: