=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992431969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LYMPHWORKS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2022
-----------------------------------------------------
Last Update Date | 08/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 VICTOR DR
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30518-2563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-310-8100
-----------------------------------------------------
Fax | 833-760-2107
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 VICTOR DR
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30518-2563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-310-8100
-----------------------------------------------------
Fax | 833-760-2107
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SAMANTHA CANNON MARTIN
-----------------------------------------------------
Credential | MSOT/L, CLT, CLWT
-----------------------------------------------------
Telephone | 770-310-8100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------