Provider Demographics
NPI:1568652972
Name:CLUB STAFFING
Entity Type:Organization
Organization Name:CLUB STAFFING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SONOGRAPHER
Authorized Official - Prefix:MS
Authorized Official - First Name:B ENSHEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS
Authorized Official - Phone:404-444-9992
Mailing Address - Street 1:307 ELIZABETH LN
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-4694
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5901 BROKEN SOUND PKWY
Practice Address - Street 2:SUITE 500
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-2773
Practice Address - Country:US
Practice Address - Phone:800-875-8999
Practice Address - Fax:561-417-7443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14796282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital