Healthcare Provider Details

I. General information

NPI: 1265844468
Provider Name (Legal Business Name): BJ MED CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1867 LAWRENCEVILLE HWY
DECATUR GA
30033-5729
US

IV. Provider business mailing address

1867 LAWRENCEVILLE HWY
DECATUR GA
30033-5729
US

V. Phone/Fax

Practice location:
  • Phone: 678-395-5035
  • Fax:
Mailing address:
  • Phone: 678-395-5035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name: SANDRA JONES
Title or Position: ADMINSTRATOR
Credential:
Phone: 678-395-5035