=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881245223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | US DEPARTMENT OF VETERANS AFFAIRS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2019
-----------------------------------------------------
Last Update Date | 09/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1670 CLAIRMONT RD
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30033-4004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-321-6111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7675 LANIER VIEW RDG
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30041-2162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-844-1909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROSTHETIST
-----------------------------------------------------
Name | MR. KELLY DEAN WINTER
-----------------------------------------------------
Credential | CP
-----------------------------------------------------
Telephone | 404-321-6111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0900X
-----------------------------------------------------
Taxonomy Name | Amputee Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------