Healthcare Provider Details

I. General information

NPI: 1699216416
Provider Name (Legal Business Name): ABVA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4565 ROCKMART RD SE UNIT 1261
SILVER CREEK GA
30173-2442
US

IV. Provider business mailing address

4565 ROCKMART RD SE UNIT 1261
SILVER CREEK GA
30173-2442
US

V. Phone/Fax

Practice location:
  • Phone: 706-386-1176
  • Fax:
Mailing address:
  • Phone: 706-386-1176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number67623
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CHAD BRAND HESS
Title or Position: OFFICE MANAGER
Credential:
Phone: 706-338-1176