Healthcare Provider Details

I. General information

NPI: 1871934323
Provider Name (Legal Business Name): CLINICA SANTA MARIA 2, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 07/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6158 HIGHWAY 92 STE 101
ACWORTH GA
30102-2332
US

IV. Provider business mailing address

6158 HIGHWAY 92 STE 101
ACWORTH GA
30102-2332
US

V. Phone/Fax

Practice location:
  • Phone: 770-928-8450
  • Fax: 770-928-8452
Mailing address:
  • Phone: 770-928-8450
  • Fax: 770-928-8452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ANTONIO MENDOZA
Title or Position: OFFICE MANAGER
Credential:
Phone: 770-928-8450