Healthcare Provider Details

I. General information

NPI: 1306319256
Provider Name (Legal Business Name): WEST GEORGIA HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2019
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 SOUTH ST
CARROLLTON GA
30117-3738
US

IV. Provider business mailing address

210 SOUTH ST
CARROLLTON GA
30117-3738
US

V. Phone/Fax

Practice location:
  • Phone: 770-834-1898
  • Fax: 770-834-4814
Mailing address:
  • Phone: 770-834-1898
  • Fax: 770-834-4814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL MIELCARSKI
Title or Position: OWNER
Credential: DC
Phone: 678-462-4402