Healthcare Provider Details

I. General information

NPI: 1881422855
Provider Name (Legal Business Name): MILAGROS J CORDERO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 PERIMETER PARK DR
CHAMBLEE GA
30341-1317
US

IV. Provider business mailing address

2320 PERIMETER PARK DR
CHAMBLEE GA
30341-1317
US

V. Phone/Fax

Practice location:
  • Phone: 770-393-9901
  • Fax: 770-936-4601
Mailing address:
  • Phone: 770-393-9901
  • Fax: 770-936-4601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT000319
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: