Provider Demographics
NPI:1437807195
Name:WALKER, ANTONIO
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:WALKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 HIGHWAY 42 STE 312
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-4105
Mailing Address - Country:US
Mailing Address - Phone:404-936-1251
Mailing Address - Fax:
Practice Address - Street 1:329 NORWAY SPRUCE CT
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-2073
Practice Address - Country:US
Practice Address - Phone:770-919-4997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA310400000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No172A00000XOther Service ProvidersDriverGroup - Multi-Specialty