Healthcare Provider Details

I. General information

NPI: 1689519829
Provider Name (Legal Business Name): MR. MICHAEL M. ALLEN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 MAIN ST STE 13
PORTERDALE GA
30014-3438
US

IV. Provider business mailing address

2104 MAIN ST STE 13
PORTERDALE GA
30014-3438
US

V. Phone/Fax

Practice location:
  • Phone: 678-972-6944
  • Fax:
Mailing address:
  • Phone: 678-972-6944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberBR018475
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: