Facts
- Status
- A
- Credential
- OTR/L
- Type
- Individual
- Enumeration date
- 2022-07-28
- Last updated
- 2022-07-28
Specialties
Licenses
- License GA
- OT008551
Location
- Practice location
- 536 GRAND SLAM DR STE D
- City
- EVANS GA
- Postal code
- 308098045
- Phone
- 706-854-8434
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.