=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063687267
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN SURGICAL ASSISTANTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2008
-----------------------------------------------------
Last Update Date | 11/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5742 ALLEE WAY
-----------------------------------------------------
City | BRASELTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-591-8344
-----------------------------------------------------
Fax | 770-965-3365
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7042
-----------------------------------------------------
City | CHESTNUT MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30502-0042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-591-8344
-----------------------------------------------------
Fax | 770-965-3365
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSEPH HENRY KANCLERZ
-----------------------------------------------------
Credential | ARNP, RNFA
-----------------------------------------------------
Telephone | 678-591-8644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------