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NPI Code Detail

MEDICARE: GA SPROUT MC 1 LLC

MEDICARE: GA SPROUT MC 1 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
1103K00000XBehavior Analyst

General Provider Information

NPI Number : 1831728039
Entity Type Code : Organization
Provider Name (Legal Business Name) : GA SPROUT MC 1 LLC
Provider Business Mailing Address
First Line : 3455 PEACHTREE RD NE FL 5
Second Line :
City : ATLANTA
State : GA
Zip : 30326-3254
Country : US
Telephone Number : 833-991-2368
Fax Number : 929-384-7193
Provider Business Practice Location Address
First Line : 3455 PEACHTREE RD NE FL 5
Second Line :
City : ATLANTA
State : GA
Zip : 30326-3254
Country : US
Telephone Number : 833-991-2368
Fax Number : 929-384-7193
Authorized Official
Title or Position : OWNER
Name : YURY YAKUBCHYK SR.
Credential :
Telephone Number : 404-738-7658
Provider Enumeration Date : 04/08/2020
Last Update Date : 09/27/2021

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Directions to “GA SPROUT MC 1 LLC ” Practice Location

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