=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760434427
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DALTON EAR NOSE & THROAT ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2006
-----------------------------------------------------
Last Update Date | 04/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1436 CHATTANOOGA AVE
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30720-2637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-226-2142
-----------------------------------------------------
Fax | 706-272-3997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1436 CHATTANOOGA AVE
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30720-2637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-226-2142
-----------------------------------------------------
Fax | 706-272-3997
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASC DIRECTOR
-----------------------------------------------------
Name | MR. DAVID L TRAMMELL
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 706-226-2142
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | DHR 20020475
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------