Healthcare Provider Details

I. General information

NPI: 1609312487
Provider Name (Legal Business Name): ALAMO HEALTH GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4816 ASHFORD LN
ATLANTA GA
30338-2650
US

IV. Provider business mailing address

PO BOX 501741
ATLANTA GA
31150-1741
US

V. Phone/Fax

Practice location:
  • Phone: 770-652-3667
  • Fax:
Mailing address:
  • Phone: 770-652-3667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. MARK REZNIK
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 770-652-3667