Provider Demographics
NPI:1386213403
Name:BUTLER, RAYMOND T
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:T
Last Name:BUTLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2769 KILGORE RD
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-4444
Mailing Address - Country:US
Mailing Address - Phone:678-482-9313
Mailing Address - Fax:
Practice Address - Street 1:2769 KILGORE RD
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4444
Practice Address - Country:US
Practice Address - Phone:678-482-9313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0000000000OtherPERSONAL CARE HOME