Healthcare Provider Details

I. General information

NPI: 1083986681
Provider Name (Legal Business Name): BRIDGEMILL FAMILY HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2012
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3760 SIXES RD SUITE 120
CANTON GA
30114-8192
US

IV. Provider business mailing address

3760 SIXES RD SUITE 120
CANTON GA
30114-8192
US

V. Phone/Fax

Practice location:
  • Phone: 770-704-4580
  • Fax:
Mailing address:
  • Phone: 770-704-4580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: MR. OTIS BONNER III
Title or Position: ATTORNEY
Credential:
Phone: 770-866-5488