Healthcare Provider Details

I. General information

NPI: 1770709628
Provider Name (Legal Business Name): CHARLES TRUMAN COLBERT JR. C.S.T./C.F.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 03/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 PROFESSIONAL PL SUITE A
RIVERDALE GA
30274-2519
US

IV. Provider business mailing address

334 DYLAN WAY
MCDONOUGH GA
30252-6186
US

V. Phone/Fax

Practice location:
  • Phone: 770-991-1150
  • Fax: 770-991-1155
Mailing address:
  • Phone: 770-914-1517
  • Fax: 770-991-1155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: