Provider Demographics
NPI:1740726454
Name:SAMBULA, JIMMY BRIAN
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:BRIAN
Last Name:SAMBULA
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 1:340 PECAN WOOD CIRCLE
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213
Mailing Address - Country:US
Mailing Address - Phone:770-895-1313
Mailing Address - Fax:
Practice Address - Street 1:1017 FAYETTEVILLE RD. SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316
Practice Address - Country:US
Practice Address - Phone:404-486-9034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician