=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841418225
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN CRESEANT SURGICAL ASSISTANTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7615 MOUNT ZION BLVD
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30236-7934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-985-4257
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 162749
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30321-2749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-985-4257
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RONALD JENNINGS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-985-4257
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------