Healthcare Provider Details

I. General information

NPI: 1801175658
Provider Name (Legal Business Name): MEDPRIME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2011
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 PEACHTREE ST SUITE A-01
ATLANTA GA
30303-1601
US

IV. Provider business mailing address

PO BOX 501741
ATLANTA GA
31150-1741
US

V. Phone/Fax

Practice location:
  • Phone: 404-522-5552
  • Fax: 404-522-5151
Mailing address:
  • Phone: 404-522-5552
  • Fax: 404-522-5151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIRO07312
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number044023
License Number StateGA

VIII. Authorized Official

Name: MARK REZNIK
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 404-522-5552