Provider Demographics
NPI:1356410062
Name:BRETTS SHOES AND VANITY FAIR
Entity type:Organization
Organization Name:BRETTS SHOES AND VANITY FAIR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:BRETT
Authorized Official - Last Name:BUCHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-866-9972
Mailing Address - Street 1:1600 MCFARLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30741-2266
Mailing Address - Country:US
Mailing Address - Phone:706-866-9972
Mailing Address - Fax:706-866-9972
Practice Address - Street 1:1600 MCFARLAND AVE
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30741-2266
Practice Address - Country:US
Practice Address - Phone:706-866-9972
Practice Address - Fax:706-866-9972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000065332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4626860001Medicare ID - Type UnspecifiedPR0VIDER