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General NPI Number Information
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NPI Number | 1316335078
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Entity Type | Organization
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Legal Business Name | THRIVE COMMUNITY OUTREACH
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Dates
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Enumeration Date | 01/05/2015
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Last Update Date | 01/05/2015
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Provider Practice Location Address
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Address Line | 230 S CULVER ST
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4806
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Country | US
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Telephone | 770-449-2151
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Fax |
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Provider Business Mailing Address
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Address Line | 230 S CULVER ST
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4806
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Country | US
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Telephone | 770-449-2151
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | TAREN LAZZARI
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Credential | NP
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Telephone | 770-449-2151
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | 028884
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 364SP0810X
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Taxonomy Name | Child & Family Psychiatric/Mental Health Clinical Nurse Specialist
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License Number | RN124271
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License Number State | GA
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