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General NPI Number Information
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NPI Number | 1326830555
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Entity Type | Individual
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Provider Name | DEREK MCKIBBEN
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Gender | Male
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Dates
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Enumeration Date | 05/22/2025
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Last Update Date | 05/22/2025
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Provider Practice Location Address
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Address Line | 375 SHILOH RD
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City | JENKINSBURG
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State | GA
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Zip | 30234-2422
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Country | US
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Telephone | 404-973-9763
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Fax | 470-771-5123
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Provider Business Mailing Address
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Address Line | 375 SHILOH RD
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City | JENKINSBURG
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State | GA
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Zip | 30234-2422
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Country | US
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Telephone | 404-973-9763
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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 | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number |
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License Number State |
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