Healthcare Provider Details

I. General information

NPI: 1609194620
Provider Name (Legal Business Name): ATLANTA LIFESTYLE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2010
Last Update Date: 05/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 PONCE DE LEON AVE NE SUITE 230
ATLANTA GA
30308-1962
US

IV. Provider business mailing address

6090 INDIAN WOOD CIR SE
MABLETON GA
30126-2969
US

V. Phone/Fax

Practice location:
  • Phone: 404-769-3928
  • Fax:
Mailing address:
  • Phone: 404-691-4549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number033801
License Number StateGA

VIII. Authorized Official

Name: DR. JENNIFER ROOKE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 404-769-3928