Healthcare Provider Details

I. General information

NPI: 1497411292
Provider Name (Legal Business Name): PEACHTREE RNFA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 E PONCE DE LEON AVE
DECATUR GA
30030-2036
US

IV. Provider business mailing address

PO BOX 2550
ROWLETT TX
75030-2550
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number
License Number State

VIII. Authorized Official

Name: NORMA D BROCK
Title or Position: OWNER
Credential: RNFA
Phone: 770-853-1974