Basic Information
| Provider Information | |||||||||
| NPI: | 1093242422 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LALA LAND ANESTHESIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 276 BELFLOWER RD | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317941607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293928840 | ||||||||
| FaxNumber: | 4783336117 | ||||||||
| Practice Location | |||||||||
| Address1: | 276 BELFLOWER RD | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317941607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293928840 | ||||||||
| FaxNumber: | 4783336117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | CONNELL | ||||||||
| AuthorizedOfficialFirstName: | DUSTIN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2293928840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN167296 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.