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General NPI Number Information
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NPI Number | 1255372041
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Entity Type | Organization
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Legal Business Name | VANITCHA R PINTAVORN
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Dates
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Enumeration Date | 06/10/2006
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Last Update Date | 07/11/2008
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Provider Practice Location Address
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Address Line | 418 TOWN PARK BLVD STE 1A
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City | EVANS
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State | GA
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Zip | 30809-3090
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Country | US
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Telephone | 706-650-1662
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Fax | 706-854-2131
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Provider Business Mailing Address
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Address Line | 418 TOWN PARK BLVD STE 1A
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City | EVANS
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State | GA
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Zip | 30809-3090
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Country | US
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Telephone | 706-650-1662
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Fax | 706-854-2131
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Authorized Official
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Title or Position | OWNER
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Name | DR. VANITCHA R PINTAVORN
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Credential | MD
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Telephone | 706-650-1662
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207KA0200X
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Taxonomy Name | Allergy Physician
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License Number | 048291
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License Number State | GA
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