Healthcare Provider Details

I. General information

NPI: 1164183315
Provider Name (Legal Business Name): PERRIS HULL SPECIALIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2022
Last Update Date: 01/09/2022
Certification Date: 01/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 PARK AVENUE
WINDER GA
30680
US

IV. Provider business mailing address

647 ARBOR RIDGE
LOGANVILLE GA
30052
US

V. Phone/Fax

Practice location:
  • Phone: 706-224-8114
  • Fax:
Mailing address:
  • Phone: 706-224-8114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCO078848
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: