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General NPI Number Information
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NPI Number | 1720262363
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Entity Type | Organization
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Legal Business Name | BABYBOOMERS
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Dates
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Enumeration Date | 12/18/2007
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Last Update Date | 12/18/2007
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Provider Practice Location Address
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Address Line | 2053 STANTON RD
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City | EAST POINT
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State | GA
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Zip | 30344-1311
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Country | US
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Telephone | 404-768-2030
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Fax |
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Provider Business Mailing Address
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Address Line | 2053 STANTON RD
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City | EAST POINT
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State | GA
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Zip | 30344-1311
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Country | US
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Telephone | 404-768-2030
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | MS. RENATA JOHNSON
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Credential |
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Telephone | 678-779-9061
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BP3500X
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Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
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License Number |
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License Number State |
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