Provider Demographics
NPI:1639962343
Name:VARNEY, OCTAVIUS
Entity type:Individual
Prefix:
First Name:OCTAVIUS
Middle Name:
Last Name:VARNEY
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 1:1214 BROCKETT WAY
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-3055
Mailing Address - Country:US
Mailing Address - Phone:678-472-5193
Mailing Address - Fax:
Practice Address - Street 1:9582 TARA BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-6089
Practice Address - Country:US
Practice Address - Phone:678-472-5193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-26
Last Update Date:2025-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056040015343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)