Provider Demographics
NPI:1871287250
Name:EBT HOLDINGS OF GEORGIA INCORPORATED
Entity type:Organization
Organization Name:EBT HOLDINGS OF GEORGIA INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSUET VALDES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-352-7021
Mailing Address - Street 1:1430 FIVE FORKS TRICKUM RD STE 220
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-8183
Mailing Address - Country:US
Mailing Address - Phone:786-352-7021
Mailing Address - Fax:786-698-1632
Practice Address - Street 1:1430 FIVE FORKS TRICKUM RD STE 220
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-8183
Practice Address - Country:US
Practice Address - Phone:786-352-7021
Practice Address - Fax:786-698-1632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-07
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty