Healthcare Provider Details

I. General information

NPI: 1104197797
Provider Name (Legal Business Name): LIFE CYCLE OB/GYN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 01/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3886 PRINCETON LAKES WAY SW SUITE 160
ATLANTA GA
30331-5511
US

IV. Provider business mailing address

2739 FELTON DR
EAST POINT GA
30344-3603
US

V. Phone/Fax

Practice location:
  • Phone: 404-530-3060
  • Fax: 404-344-7511
Mailing address:
  • Phone: 404-766-8371
  • Fax: 404-767-3926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number045937
License Number StateGA

VIII. Authorized Official

Name: ANNE SIGOUIN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 404-766-8371