Healthcare Provider Details

I. General information

NPI: 1992301402
Provider Name (Legal Business Name): PROGRESSIVE MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2098 TERON TRCE STE 300
DACULA GA
30019-1667
US

IV. Provider business mailing address

2098 TERON TRCE STE 300
DACULA GA
30019-1667
US

V. Phone/Fax

Practice location:
  • Phone: 770-614-4060
  • Fax: 678-482-7788
Mailing address:
  • Phone: 770-614-4060
  • Fax: 678-482-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN MITCHELL
Title or Position: OWNER
Credential:
Phone: 770-614-4060