Basic Information
| Provider Information | |||||||||
| NPI: | 1063014561 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KERKULA | ||||||||
| FirstName: | KOLUBAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 MILL CREEK PL | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300762062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078072973 | ||||||||
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| Practice Location | |||||||||
| Address1: | 465 WINN WAY | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300301753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4704032830 | ||||||||
| FaxNumber: | 4704275560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2020 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-20-132442 | FL | Y |
No ID Information.