Healthcare Provider Details

I. General information

NPI: 1609190198
Provider Name (Legal Business Name): INMED CLINICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2010
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

563 MOUNTAIN CITY RD
CLAYTON GA
30525-3072
US

IV. Provider business mailing address

331 RIDGECREST CIR
CLAYTON GA
30525-4186
US

V. Phone/Fax

Practice location:
  • Phone: 706-960-9026
  • Fax: 404-698-2588
Mailing address:
  • Phone: 706-782-0471
  • Fax: 404-698-2588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELE MARTIN
Title or Position: CREDENTIALING
Credential:
Phone: 706-782-0471