Provider Demographics
NPI:1558979591
Name:BUSANTE, VINCENT JOHN R
Entity Type:Individual
Prefix:
First Name:VINCENT JOHN
Middle Name:R
Last Name:BUSANTE
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 1:2200 OLD QUACCO RD # ATP5204
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-0558
Mailing Address - Country:US
Mailing Address - Phone:757-515-9110
Mailing Address - Fax:
Practice Address - Street 1:247 S MAIN ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30453-4605
Practice Address - Country:US
Practice Address - Phone:912-557-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007769225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist