Provider Demographics
NPI:1003810748
Name:PEACHSTATE PROSTHETICS AND ORTHOTICS, INC
Entity Type:Organization
Organization Name:PEACHSTATE PROSTHETICS AND ORTHOTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:SEMMES
Authorized Official - Suffix:
Authorized Official - Credentials:LCPO
Authorized Official - Phone:706-400-5750
Mailing Address - Street 1:178 BRACKETTS WAY STE 3
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-2984
Mailing Address - Country:US
Mailing Address - Phone:706-400-5750
Mailing Address - Fax:706-400-5751
Practice Address - Street 1:178 BRACKETTS WAY STE 3
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-2984
Practice Address - Country:US
Practice Address - Phone:706-400-5750
Practice Address - Fax:706-400-5751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000690852AMedicaid
GA20010497912OtherSTATE SALES TAX ID
GA1003810748OtherNPI
GALPO#000004OtherCOMPOSITE MEDICAL BOARD
GA20010497912OtherSTATE SALES TAX ID