Healthcare Provider Details

I. General information

NPI: 1992111280
Provider Name (Legal Business Name): LIFEQUEST KENNESAW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3362 ACWORTH SUMMIT BLVD NW
ACWORTH GA
30101-5770
US

IV. Provider business mailing address

3362 ACWORTH SUMMIT BLVD NW
ACWORTH GA
30101-5770
US

V. Phone/Fax

Practice location:
  • Phone: 678-973-0635
  • Fax:
Mailing address:
  • Phone: 678-973-0635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number33753
License Number StateGA

VIII. Authorized Official

Name: JAMES BROUSSARD
Title or Position: VICE PRESIDENT
Credential:
Phone: 678-973-0635