Provider Demographics
NPI:1912627126
Name:ANTONIO LUIS, M.D., LLC
Entity Type:Organization
Organization Name:ANTONIO LUIS, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-295-0526
Mailing Address - Street 1:1013 FERNWOOD DR STE C
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-5428
Mailing Address - Country:US
Mailing Address - Phone:478-251-6924
Mailing Address - Fax:478-295-3644
Practice Address - Street 1:1013 FERNWOOD DR STE C
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-5428
Practice Address - Country:US
Practice Address - Phone:478-251-6924
Practice Address - Fax:478-295-3644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-29
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)