Provider Demographics
NPI:1366612319
Name:GREGORY, JANIS D (LMT)
Entity type:Individual
Prefix:
First Name:JANIS
Middle Name:D
Last Name:GREGORY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2258 WRIGHTSBORO RD STE 250
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-7605
Mailing Address - Country:US
Mailing Address - Phone:706-724-6543
Mailing Address - Fax:206-350-9023
Practice Address - Street 1:2258 WRIGHTSBORO RD STE 250
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-7605
Practice Address - Country:US
Practice Address - Phone:706-724-6543
Practice Address - Fax:206-350-9023
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2345174400000X
GAMT003552174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist