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General NPI Number Information
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NPI Number | 1144788142
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Entity Type | Organization
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Legal Business Name | JAYTYN LLC
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Dates
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Enumeration Date | 03/08/2019
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Last Update Date | 04/24/2019
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Provider Practice Location Address
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Address Line | 4600 BROSWELL ROAD
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City | ATLANTA
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State | GA
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Zip | 30342
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Country | US
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Telephone | 256-457-3071
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Fax |
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Provider Business Mailing Address
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Address Line | 4310 BRONTE LN
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City | DOUGLASVILLE
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State | GA
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Zip | 30135-4981
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Country | US
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Telephone | 256-457-3071
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Fax |
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Authorized Official
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Title or Position | MD
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Name | JOHNY LEE BONNER SR.
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Credential |
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Telephone | 256-457-3071
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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