=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487297164
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEAVMED L.L.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2019
-----------------------------------------------------
Last Update Date | 12/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3915 CASCADE RD SW STE T-90
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-8660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-925-5884
-----------------------------------------------------
Fax | 888-440-7722
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1481 BOURDON BELL DR SE
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30013-7459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-925-5884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEMBER
-----------------------------------------------------
Name | DR. TODD DEAVENS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 770-925-5884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------