=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033582713
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REGAIL'S ENTERPRISES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2015
-----------------------------------------------------
Last Update Date | 11/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5116 VERBENA DR NW
-----------------------------------------------------
City | ACWORTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30102-6923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-630-8997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5116 VERBENA DR NW
-----------------------------------------------------
City | ACWORTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30102-6923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-630-8997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT
-----------------------------------------------------
Name | MRS. GEORGETTE ANTHONY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-630-8997
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------