Healthcare Provider Details

I. General information

NPI: 1639402415
Provider Name (Legal Business Name): CLINICA UNION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3369 BUFORD HWY NE SUITE 810
ATLANTA GA
30329-3722
US

IV. Provider business mailing address

3369 BUFORD HWY NE SUITE 810
ATLANTA GA
30329-3722
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-4692
  • Fax:
Mailing address:
  • Phone: 404-321-4692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIO RIVERA
Title or Position: PRESIDENT & CEO
Credential:
Phone: 404-321-4692