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General NPI Number Information
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NPI Number | 1205258431
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Entity Type | Individual
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Provider Name | MR. GARY STEVEN KOLLER
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Gender | Male
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Dates
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Enumeration Date | 01/07/2014
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Last Update Date | 06/30/2015
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Provider Practice Location Address
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Address Line | 76 HOLDER ROAD
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City | LUMPKIN
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State | GA
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Zip | 31815
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Country | US
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Telephone | 229-838-1241
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Fax | 229-838-1242
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Provider Business Mailing Address
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Address Line | 79 HOLDER ROAD
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City | LUMPKIN
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State | GA
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Zip | 31815
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Country | US
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Telephone | 229-838-1241
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 364SF0001X
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Taxonomy Name | Family Health Clinical Nurse Specialist
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License Number | RN218792
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License Number State | GA
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