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General NPI Number Information
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NPI Number | 1255194932
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Entity Type | Individual
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Provider Name | DEANDREA THORNTON JR. CSCS
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Gender | Male
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Dates
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Enumeration Date | 02/05/2024
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Last Update Date | 02/05/2024
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Provider Practice Location Address
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Address Line | 1525 SENOIA RD STE D
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City | TYRONE
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State | GA
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Zip | 30290-3602
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Country | US
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Telephone | 770-861-4321
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Fax |
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Provider Business Mailing Address
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Address Line | 5735 UNION POINTE DR
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City | UNION CITY
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State | GA
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Zip | 30291-1648
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Country | US
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Telephone |
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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 | 171400000X
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Taxonomy Name | Health & Wellness Coach
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License Number | 7248208737
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License Number State | GA
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