Healthcare Provider Details

I. General information

NPI: 1922273747
Provider Name (Legal Business Name): SOUTHERN HEALTHCARE PROVIDER GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2754 N DECATUR RD SUITE 110
DECATUR GA
30033-5917
US

IV. Provider business mailing address

PO BOX 6881
MARIETTA GA
30065-0881
US

V. Phone/Fax

Practice location:
  • Phone: 404-838-0082
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCHIRO07897
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number021447
License Number StateGA

VIII. Authorized Official

Name: NELSON MEDRANO
Title or Position: CLINIC DIRECTOR
Credential:
Phone: 770-792-7893