Provider Demographics
NPI:1831728039
Name:GA SPROUT MC 1 LLC
Entity type:Organization
Organization Name:GA SPROUT MC 1 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YURY
Authorized Official - Middle Name:
Authorized Official - Last Name:YAKUBCHYK
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:404-738-7658
Mailing Address - Street 1:3455 PEACHTREE RD NE FL 5
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-3254
Mailing Address - Country:US
Mailing Address - Phone:833-991-2368
Mailing Address - Fax:929-384-7193
Practice Address - Street 1:3455 PEACHTREE RD NE FL 5
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30326-3254
Practice Address - Country:US
Practice Address - Phone:833-991-2368
Practice Address - Fax:929-384-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-08
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty