=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396476461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICALS & HEALTH MATTERS MOBILE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2022
-----------------------------------------------------
Last Update Date | 06/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6595 ROSWELL RD
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-3152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-523-5523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6595 ROSWELL RD
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-3152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-523-5523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEJANAY DAWSON
-----------------------------------------------------
Credential | RMA
-----------------------------------------------------
Telephone | 470-227-5458
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------