Provider Demographics
NPI:1396188967
Name:LAGNIAPPE LLC
Entity Type:Organization
Organization Name:LAGNIAPPE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:T
Authorized Official - Last Name:CLAVO
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:770-632-3730
Mailing Address - Street 1:1975 HIGHWAY 54 W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4794
Mailing Address - Country:US
Mailing Address - Phone:770-632-3730
Mailing Address - Fax:770-632-3731
Practice Address - Street 1:1975 HIGHWAY 54 W
Practice Address - Street 2:SUITE 100
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4794
Practice Address - Country:US
Practice Address - Phone:770-632-3730
Practice Address - Fax:770-632-3731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0666736261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical