MEDICARE: DRACO GROUP OF MARIETTA, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1184810913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DRACO GROUP OF MARIETTA, INC.

Provider Business Mailing Address
First Line	:	3020 ROSWELL RD STE 216-A
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30062-4996
Country	:	US
Telephone Number	:	678-819-3936
Fax Number	:	678-819-3943

Provider Business Practice Location Address
First Line	:	3020 ROSWELL RD STE 216-A
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30062-4996
Country	:	US
Telephone Number	:	678-819-3936
Fax Number	:	678-819-3943

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BERNARDO MATOS
Credential	:
Telephone Number	:	678-819-3936

Provider Enumeration Date	:	09/14/2007
Last Update Date	:	09/14/2007

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