Provider Demographics
NPI:1871877159
Name:SKATES-N-MOTION
Entity type:Organization
Organization Name:SKATES-N-MOTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:LORENZO
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-914-1912
Mailing Address - Street 1:296 ROY HUIE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-1867
Mailing Address - Country:US
Mailing Address - Phone:404-914-1912
Mailing Address - Fax:
Practice Address - Street 1:5878 COVINGTON HWY STE E
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-3745
Practice Address - Country:US
Practice Address - Phone:404-914-1912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization