=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255668810
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE NEUROPSYCHIATRIC CLINIC OF ATLANTIS-VILLA RICA, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2009
-----------------------------------------------------
Last Update Date | 11/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 690 DALLAS HWY STE 201
-----------------------------------------------------
City | VILLA RICA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30180-1263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-840-8446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 690 DALLAS HWY STE 201
-----------------------------------------------------
City | VILLA RICA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30180-1263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | DR. RANDY TYLER WARNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-840-8446
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 053905
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------