Basic Information
Provider Information | |||||||||
NPI: | 1780224030 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AMERITA SOUTH ATLANTIC LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVANCED HOME INFUSION | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6912 S QUENTIN ST SUITE 50 | ||||||||
Address2: |   | ||||||||
City: | CENTENNIAL | ||||||||
State: | CO | ||||||||
PostalCode: | 80112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7202825411 | ||||||||
FaxNumber: | 8773025251 | ||||||||
Practice Location | |||||||||
Address1: | 5901 GOSHEN SPRINGS RD STE H | ||||||||
Address2: |   | ||||||||
City: | NORCROSS | ||||||||
State: | GA | ||||||||
PostalCode: | 300713506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7705003834 | ||||||||
FaxNumber: | 8339940847 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/14/2020 | ||||||||
LastUpdateDate: | 10/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | IRIYE | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7202822377 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | AMERITA, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | AO | ||||||||
NPICertificationDate: | 10/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 332BP3500X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 3336H0001X |   |   | Y |   | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 1174488 | 01 |   | NCPDP | OTHER |