Provider Demographics
NPI:1720262363
Name:BABYBOOMERS
Entity type:Organization
Organization Name:BABYBOOMERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MS
Authorized Official - First Name:RENATA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-779-9061
Mailing Address - Street 1:2053 STANTON RD
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-1311
Mailing Address - Country:US
Mailing Address - Phone:404-768-2030
Mailing Address - Fax:
Practice Address - Street 1:2053 STANTON RD
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-1311
Practice Address - Country:US
Practice Address - Phone:404-768-2030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition