Healthcare Provider Details

I. General information

NPI: 1104208537
Provider Name (Legal Business Name): ROSEMARIE BERGHOUT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2049 PERKERSON RD SW
ATLANTA GA
30310-5052
US

IV. Provider business mailing address

2049 PERKERSON RD SW
ATLANTA GA
30310-5052
US

V. Phone/Fax

Practice location:
  • Phone: 404-549-9327
  • Fax: 404-963-5017
Mailing address:
  • Phone: 404-549-9327
  • Fax: 404-963-5017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number172V0000X
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: