Healthcare Provider Details

I. General information

NPI: 1073881405
Provider Name (Legal Business Name): HAMILTON MILL FAMILY COMPLETE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 BRASELTON HWY BUILDING F
DACULA GA
30019-1107
US

IV. Provider business mailing address

3509 BRASELTON HWY BUILDING F
DACULA GA
30019-1107
US

V. Phone/Fax

Practice location:
  • Phone: 770-614-6630
  • Fax: 770-614-6684
Mailing address:
  • Phone: 770-614-6630
  • Fax: 770-614-6684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number176596
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number07581
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. RUSSELL GLASSMAN
Title or Position: MEMBER/MANAGER
Credential:
Phone: 770-614-6630