Provider Demographics
NPI:1336325307
Name:ALLEN, ROBERT RAEGAN III (CNIM)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:RAEGAN
Last Name:ALLEN
Suffix:III
Gender:M
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5185 YOUNG DEER DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-8964
Mailing Address - Country:US
Mailing Address - Phone:770-889-9806
Mailing Address - Fax:
Practice Address - Street 1:6250 SHILOH RD STE 110
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-8400
Practice Address - Country:US
Practice Address - Phone:770-781-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-21
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other