Healthcare Provider Details

I. General information

NPI: 1720466345
Provider Name (Legal Business Name): JUSTIN FRISBEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2015
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 KING RD
RIVERDALE GA
30274-2027
US

IV. Provider business mailing address

8060 WEBB RD UNIT 741235
RIVERDALE GA
30274-5406
US

V. Phone/Fax

Practice location:
  • Phone: 770-991-7788
  • Fax: 770-991-7727
Mailing address:
  • Phone: 770-991-7788
  • Fax: 770-991-7727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: