Provider Demographics
NPI:1083770655
Name:TILLEY, JOHN MARTIN (OTR L)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARTIN
Last Name:TILLEY
Suffix:
Gender:M
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 BOLLING CV
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-2430
Mailing Address - Country:US
Mailing Address - Phone:678-442-8109
Mailing Address - Fax:678-442-5995
Practice Address - Street 1:801 BOLLING CV
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-2430
Practice Address - Country:US
Practice Address - Phone:678-442-8109
Practice Address - Fax:678-442-5995
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002798174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist