=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396234282
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICALS PLUS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2018
-----------------------------------------------------
Last Update Date | 05/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3188 ATLANTA RD SE
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-8256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-903-8019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 328 VININGS PKWY SE
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-3906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-903-8019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CRYSTAL NP-C BERRY
-----------------------------------------------------
Credential | NP-C
-----------------------------------------------------
Telephone | 404-903-8019
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | NCO-000001
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------