Healthcare Provider Details

I. General information

NPI: 1750721221
Provider Name (Legal Business Name): INTERNATIONAL COMMUNITY MEDICAL NETWORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 06/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 WINDSOR DR SW
ATLANTA GA
30311-4414
US

IV. Provider business mailing address

1900 WINDSOR DR SW
ATLANTA GA
30311-4414
US

V. Phone/Fax

Practice location:
  • Phone: 559-455-3934
  • Fax:
Mailing address:
  • Phone: 559-455-3934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: KWAME MAKINI
Title or Position: CEO
Credential:
Phone: 559-455-3934