Healthcare Provider Details

I. General information

NPI: 1285553875
Provider Name (Legal Business Name): RENALDO RENATO SERGINHO EBANKS JR. N/A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 ROSWELL RD STE 1
SANDY SPRINGS GA
30342-2684
US

IV. Provider business mailing address

72 MILTON AVE SE
ATLANTA GA
30315-2304
US

V. Phone/Fax

Practice location:
  • Phone: 470-258-4050
  • Fax:
Mailing address:
  • Phone: 678-760-9805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: