Healthcare Provider Details

I. General information

NPI: 1649851627
Provider Name (Legal Business Name): TBI3 GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 04/20/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4319 COVINGTON HIGHWAY DECATUR STE 209
DECATUR GA
30035
US

IV. Provider business mailing address

300 COLONIAL CENTER PKWY STE 100
ROSWELL GA
30076-4892
US

V. Phone/Fax

Practice location:
  • Phone: 678-977-1792
  • Fax:
Mailing address:
  • Phone: 936-648-5161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA RUTLEDGE
Title or Position: COO
Credential:
Phone: 936-648-5161