Healthcare Provider Details

I. General information

NPI: 1740127018
Provider Name (Legal Business Name): ETHEN ROYAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 E IMPERIAL CIR
WARNER ROBINS GA
31093-2201
US

IV. Provider business mailing address

206 ORCHARD WAY
WARNER ROBINS GA
31088-4434
US

V. Phone/Fax

Practice location:
  • Phone: 478-257-1367
  • Fax:
Mailing address:
  • Phone: 478-257-1367
  • Fax: 478-257-1367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: