Healthcare Provider Details

I. General information

NPI: 1609820745
Provider Name (Legal Business Name): CHAMBLEE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3739 CHAMBLEE DUNWOODY RD
CHAMBLEE GA
30341-2062
US

IV. Provider business mailing address

PO BOX 80042
ATLANTA GA
30366-0042
US

V. Phone/Fax

Practice location:
  • Phone: 770-458-0025
  • Fax: 770-458-0807
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number026895
License Number StateGA

VIII. Authorized Official

Name: SOREN THOMAS
Title or Position: OWNER
Credential:
Phone: 770-458-0025