Healthcare Provider Details

I. General information

NPI: 1114440963
Provider Name (Legal Business Name): EAST ATLANTA ENDOSCOPY CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7229 WHEAT ST NE
COVINGTON GA
30014-1566
US

IV. Provider business mailing address

15305 DALLAS PKWY STE 1600
ADDISON TX
75001-6491
US

V. Phone/Fax

Practice location:
  • Phone: 678-625-5132
  • Fax: 678-625-5137
Mailing address:
  • Phone: 972-763-3893
  • Fax: 972-692-6745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENETHA D MORAN
Title or Position: OFFICER / AUTHORIZED OFFICIAL
Credential:
Phone: 972-763-3893