Provider Demographics
NPI:1780294926
Name:ALCANTAR, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:ALCANTAR
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 1:39 JIM LN SE
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-7824
Mailing Address - Country:US
Mailing Address - Phone:478-293-9539
Mailing Address - Fax:
Practice Address - Street 1:7340 FAIRMOUNT HWY SE
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-4023
Practice Address - Country:US
Practice Address - Phone:706-602-0320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0028022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer