Healthcare Provider Details

I. General information

NPI: 1023543246
Provider Name (Legal Business Name): ERIC CHEN CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2017
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 WHITCHER ST NE STE 2120
MARIETTA GA
30060-1180
US

IV. Provider business mailing address

61 WHITCHER ST NE STE 2120
MARIETTA GA
30060-1180
US

V. Phone/Fax

Practice location:
  • Phone: 770-544-1145
  • Fax: 770-544-1146
Mailing address:
  • Phone: 770-544-1145
  • Fax: 770-544-1146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number96
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number96
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: