MEDICARE: PEACH SEED HEALTHCARE

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	2084P0804X	Child & Adolescent Psychiatry Physician

General Provider Information

NPI Number	:	1851918999
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACH SEED HEALTHCARE

Provider Business Mailing Address
First Line	:	3455 PEACHTREE RD NE STE 500
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30326-3236
Country	:	US
Telephone Number	:	470-531-2580
Fax Number	:	470-531-2580

Provider Business Practice Location Address
First Line	:	1635 OLD 41 HWY NW STE 141
Second Line	:
City	:	KENNESAW
State	:	GA
Zip	:	30152-4480
Country	:	US
Telephone Number	:	678-400-5051
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE OWNER
Name	:	LATOYA NICOLE THOMAS
Credential	:
Telephone Number	:	470-531-2580

Provider Enumeration Date	:	07/05/2020
Last Update Date	:	12/08/2023

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