Provider Demographics
NPI:1063103778
Name:NSP1RE
Entity type:Organization
Organization Name:NSP1RE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LATORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKAON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-671-0078
Mailing Address - Street 1:5317 PEACHTREE BLVD
Mailing Address - Street 2:S306
Mailing Address - City:CHAMBLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30341
Mailing Address - Country:US
Mailing Address - Phone:678-671-0078
Mailing Address - Fax:888-948-2083
Practice Address - Street 1:5317 PEACHTREE BLVD
Practice Address - Street 2:GUARDIAN BUSINESS CENTER S306
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341
Practice Address - Country:US
Practice Address - Phone:678-671-0078
Practice Address - Fax:888-948-2083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management