Healthcare Provider Details

I. General information

NPI: 1811399090
Provider Name (Legal Business Name): ATHENS MODEL NEIGHBORHOOD HEALTH CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 MCKINLEY DR
ATHENS GA
30601-3261
US

IV. Provider business mailing address

402 MCKINLEY DR
ATHENS GA
30601-3261
US

V. Phone/Fax

Practice location:
  • Phone: 706-850-8057
  • Fax: 706-549-0056
Mailing address:
  • Phone: 706-543-1145
  • Fax: 706-549-0056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE010127
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SAMAN KAZEMI
Title or Position: PHARMACY DIRECTOR
Credential:
Phone: 706-543-1145