Provider Demographics
NPI:1780134411
Name:FASTTRACK IC ANCILLARY LLC
Entity type:Organization
Organization Name:FASTTRACK IC ANCILLARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:DERANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-728-0882
Mailing Address - Street 1:PO BOX 4380
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30023-4380
Mailing Address - Country:US
Mailing Address - Phone:888-728-0882
Mailing Address - Fax:
Practice Address - Street 1:1110 HILLCREST PKWY
Practice Address - Street 2:UNIT #C
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-3687
Practice Address - Country:US
Practice Address - Phone:478-296-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty