Healthcare Provider Details

I. General information

NPI: 1659908416
Provider Name (Legal Business Name): MENA LOUIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 CLINIC AVE STE 302C
CARROLLTON GA
30117-4454
US

IV. Provider business mailing address

157 CLINIC AVE STE 302C
CARROLLTON GA
30117-4454
US

V. Phone/Fax

Practice location:
  • Phone: 770-834-3336
  • Fax: 770-832-2331
Mailing address:
  • Phone: 770-834-3336
  • Fax: 770-832-2331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number111428
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: