Provider Demographics
NPI:1881956290
Name:MENS EXECUTIVE HEALTH SERVICES LLC
Entity type:Organization
Organization Name:MENS EXECUTIVE HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CHRIS
Authorized Official - Last Name:SALTER
Authorized Official - Suffix:
Authorized Official - Credentials:CPRN
Authorized Official - Phone:770-328-2006
Mailing Address - Street 1:1250 WATTS RD
Mailing Address - Street 2:
Mailing Address - City:BOWDON
Mailing Address - State:GA
Mailing Address - Zip Code:30108-2757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2798 JOHN HAWKINS PKWY STE 128
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-3108
Practice Address - Country:US
Practice Address - Phone:770-328-2006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1071631363L00000X
ALAL 24557207Q00000X
ALAL 20705207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty