=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851153373
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MORTUARY ARTISTS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2024
-----------------------------------------------------
Last Update Date | 02/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5701 MABLETON PKWY SW STE 108
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-3357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-964-3066
-----------------------------------------------------
Fax | 470-964-3066
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5701 MABLETON PKWY SW STE 108
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-3357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-964-3066
-----------------------------------------------------
Fax | 470-964-3066
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/BCC CHAPLAIN
-----------------------------------------------------
Name | MS. BIANCA H SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 470-964-3066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374K00000X
-----------------------------------------------------
Taxonomy Name | Religious Nonmedical Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------