Healthcare Provider Details

I. General information

NPI: 1124621487
Provider Name (Legal Business Name): KINGSLEY CLINIC OF GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11720 AMBERPARK DR STE 160
ALPHARETTA GA
30009-2271
US

IV. Provider business mailing address

33471 BILTMORE DR
TEMECULA CA
92592-1849
US

V. Phone/Fax

Practice location:
  • Phone: 770-580-1905
  • Fax: 912-216-3703
Mailing address:
  • Phone: 530-305-7637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES KINGSLEY
Title or Position: OWNER
Credential: MD
Phone: 770-580-1905