Healthcare Provider Details

I. General information

NPI: 1144416991
Provider Name (Legal Business Name): LINDA GWIN CSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2781 TOPAZ RD
RIVERDALE GA
30296-6014
US

IV. Provider business mailing address

2781 TOPAZ RD
RIVERDALE GA
30296-6014
US

V. Phone/Fax

Practice location:
  • Phone: 770-985-4257
  • Fax: 770-985-4258
Mailing address:
  • Phone: 770-985-4257
  • Fax: 770-985-4258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number3133
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: