MEDICARE: EVI ADDOH

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	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	DN122776	GA

General Provider Information

NPI Number	:	1750027728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVI ADDOH

Provider Business Mailing Address
First Line	:	4750 MAC RD APT B8
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31605-6392
Country	:	US
Telephone Number	:	662-543-0519
Fax Number	:

Provider Business Practice Location Address
First Line	:	1609 NORMAN DR STE B
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31601-3753
Country	:	US
Telephone Number	:	229-269-4607
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2022
Last Update Date	:	07/13/2022

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Directions to “ EVI ADDOH ” Practice Location

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