MEDICARE: IDEABANK, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	LPN055058	GA

General Provider Information

NPI Number	:	1528378718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDEABANK, LLC

Provider Business Mailing Address
First Line	:	2158 CUMBERLAND PKWY SE
Second Line	:	SUITE 8208
City	:	ATLANTA
State	:	GA
Zip	:	30339-4539
Country	:	US
Telephone Number	:	404-915-9902
Fax Number	:

Provider Business Practice Location Address
First Line	:	2158 CUMBERLAND PKWY SE
Second Line	:	SUITE 8208
City	:	ATLANTA
State	:	GA
Zip	:	30339-4539
Country	:	US
Telephone Number	:	404-915-9902
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	MR. TRAVIS TRAMMELL
Credential	:
Telephone Number	:	404-915-9902

Provider Enumeration Date	:	10/20/2010
Last Update Date	:	10/20/2010

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Directions to “IDEABANK, LLC ” Practice Location

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