Healthcare Provider Details

I. General information

NPI: 1518096122
Provider Name (Legal Business Name): DOMINION ORTHOPAEDIC CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 CONCOURSE PKWY STE 260
ATLANTA GA
30328-6117
US

IV. Provider business mailing address

5555 PEACHTREE DUNWOODY RD NE SUITE 215
ATLANTA GA
30342-1703
US

V. Phone/Fax

Practice location:
  • Phone: 770-455-4009
  • Fax: 770-455-4065
Mailing address:
  • Phone: 770-455-4009
  • Fax: 770-455-4065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number037539
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: RUTH CLARK
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 770-455-4009