Healthcare Provider Details

I. General information

NPI: 1023292190
Provider Name (Legal Business Name): ECC CHATSWORTH DALTON MC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 12/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MEMORIAL DRIVE
DALTON GA
30722-1168
US

IV. Provider business mailing address

P O BOX 635919
CINCINNATI OH
45263-5919
US

V. Phone/Fax

Practice location:
  • Phone: 706-272-6158
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN R STALEY JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 888-203-1274