Healthcare Provider Details

I. General information

NPI: 1932677812
Provider Name (Legal Business Name): ALFRED FORNAH CSCM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 PACES FERRY RD SE STE 750
ATLANTA GA
30339-4053
US

IV. Provider business mailing address

2727 PACES FERRY RD SE STE 750
ATLANTA GA
30339-4053
US

V. Phone/Fax

Practice location:
  • Phone: 770-694-1777
  • Fax: 678-981-4601
Mailing address:
  • Phone: 770-694-1777
  • Fax: 678-981-4601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number033-R-2053
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: