Provider Demographics
NPI:1740647692
Name:BANNER HEALTHCARE SERVICES LLC
Entity type:Organization
Organization Name:BANNER HEALTHCARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FOSTER
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-993-3824
Mailing Address - Street 1:1256 OAKBROOK DR
Mailing Address - Street 2:STE C
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-2247
Mailing Address - Country:US
Mailing Address - Phone:678-993-3824
Mailing Address - Fax:678-325-5601
Practice Address - Street 1:1256 OAKBROOK DR
Practice Address - Street 2:STE C
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-2247
Practice Address - Country:US
Practice Address - Phone:678-993-3824
Practice Address - Fax:678-325-5601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-23
Last Update Date:2016-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier