=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003567223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UN SIMPLE MINDED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2022
-----------------------------------------------------
Last Update Date | 01/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 EAGLE COVE WAY
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-5843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-975-5539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 810 EAGLE COVE WAY
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-5843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-975-5539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMIR BERNARD LANE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-975-5539
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------