Provider Demographics
NPI:1003567223
Name:UN SIMPLE MINDED
Entity Type:Organization
Organization Name:UN SIMPLE MINDED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-975-5539
Mailing Address - Street 1:810 EAGLE COVE WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-5843
Mailing Address - Country:US
Mailing Address - Phone:678-975-5539
Mailing Address - Fax:
Practice Address - Street 1:810 EAGLE COVE WAY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5843
Practice Address - Country:US
Practice Address - Phone:678-975-5539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty