Provider Demographics
NPI:1396928206
Name:WAYNE RANSOM REAVES
Entity type:Organization
Organization Name:WAYNE RANSOM REAVES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:RANSOM
Authorized Official - Last Name:REAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-549-2410
Mailing Address - Street 1:PO BOX 48174
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-8174
Mailing Address - Country:US
Mailing Address - Phone:706-549-2410
Mailing Address - Fax:706-369-8968
Practice Address - Street 1:2092 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6047
Practice Address - Country:US
Practice Address - Phone:706-549-2410
Practice Address - Fax:706-369-8968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52070313OtherBLUE CROSS BLUE SHIELD
GA4405620001Medicare NSC