Healthcare Provider Details

I. General information

NPI: 1750027728
Provider Name (Legal Business Name): EVI ADDOH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 NORMAN DR STE B
VALDOSTA GA
31601-3753
US

IV. Provider business mailing address

4750 MAC RD APT B8
VALDOSTA GA
31605-6392
US

V. Phone/Fax

Practice location:
  • Phone: 229-269-4607
  • Fax:
Mailing address:
  • Phone: 662-543-0519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN122776
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: