=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811389059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODSTONE ORTHOTICS ,PROSTHETICS & MASTECTOMY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2015
-----------------------------------------------------
Last Update Date | 02/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2330 SCENIC HWY S
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30078-3115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-838-0797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6234 WOODSTONE WAY
-----------------------------------------------------
City | MORROW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PRACTITIONER
-----------------------------------------------------
Name | SHANTEL TATUM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 470-839-0797
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------