Provider Demographics
NPI:1962920215
Name:FETTII
Entity type:Organization
Organization Name:FETTII
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANCRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-777-2665
Mailing Address - Street 1:4245 WINDALE DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-6869
Mailing Address - Country:US
Mailing Address - Phone:678-777-2665
Mailing Address - Fax:
Practice Address - Street 1:4245 WINDALE DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-6869
Practice Address - Country:US
Practice Address - Phone:678-777-2665
Practice Address - Fax:404-393-0686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier