Healthcare Provider Details

I. General information

NPI: 1669716718
Provider Name (Legal Business Name): PROFESSIONAL MEDICAL & REHAB CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2636 MARTIN LUTHER KING JR DR SW STE. 12
ATLANTA GA
30311-1634
US

IV. Provider business mailing address

2636 MARTIN LUTHER KING JR DR SW STE. 12
ATLANTA GA
30311-1634
US

V. Phone/Fax

Practice location:
  • Phone: 404-748-4952
  • Fax: 404-696-2823
Mailing address:
  • Phone: 404-748-4952
  • Fax: 404-696-2823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL LEE
Title or Position: MEMBER
Credential:
Phone: 404-748-4952