Basic Information
Provider Information | |||||||||
NPI: | 1316285802 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PEREZ | ||||||||
FirstName: | JOEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ATP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5959 SHALLOWFORD RD STE 443 | ||||||||
Address2: |   | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 374212245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4237562268 | ||||||||
FaxNumber: | 4232669690 | ||||||||
Practice Location | |||||||||
Address1: | 8313 KNIGHT RD | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770543905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7137919080 | ||||||||
FaxNumber: | 7137919084 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/18/2013 | ||||||||
LastUpdateDate: | 01/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X |   |   | Y |   | Technologists, Technicians & Other Technical Service Providers | Technician, Other |   |
No ID Information.