Healthcare Provider Details

I. General information

NPI: 1518228022
Provider Name (Legal Business Name): NORTH GEORGIA HEALTH CARE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 RIVERSTONE PKWY SUITE 140
CANTON GA
30114-5223
US

IV. Provider business mailing address

557 RIVERSTONE PKWY SUITE 140
CANTON GA
30114-5223
US

V. Phone/Fax

Practice location:
  • Phone: 770-345-2000
  • Fax: 770-345-4524
Mailing address:
  • Phone: 770-345-2000
  • Fax: 770-345-4524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number53772
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number53772
License Number StateGA

VIII. Authorized Official

Name: MR. ERIC ANTHONY CAVACIUTI
Title or Position: OWNER
Credential:
Phone: 770-345-2000