Healthcare Provider Details

I. General information

NPI: 1952737207
Provider Name (Legal Business Name): CPMSC CANTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 RIVERSTONE TERRACE SUITE 102
CANTON GA
30114
US

IV. Provider business mailing address

PO BOX 11407 DEPT 2570
BIRMINGHAM AL
35246-2570
US

V. Phone/Fax

Practice location:
  • Phone: 770-929-9033
  • Fax: 770-929-9092
Mailing address:
  • Phone: 770-929-9033
  • Fax: 770-929-9092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICTORIA BECK
Title or Position: CHIEF FINANCIAL OFFICER
Credential: CFO
Phone: 404-920-4950