Healthcare Provider Details

I. General information

NPI: 1912248345
Provider Name (Legal Business Name): JENCARE NEIGHBORHOOD MEDICAL CENTER SOUTH DEKALB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2013
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2124 CANDLER RD
DECATUR GA
30032-5572
US

IV. Provider business mailing address

1395 NW 167TH ST
MIAMI FL
33169-5710
US

V. Phone/Fax

Practice location:
  • Phone: 305-628-6117
  • Fax:
Mailing address:
  • Phone: 305-628-6117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number069385
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number069385
License Number StateGA

VIII. Authorized Official

Name: MARY CHEN
Title or Position: AUTHORIZED OFFICAL
Credential:
Phone: 305-831-4722