Healthcare Provider Details

I. General information

NPI: 1104274323
Provider Name (Legal Business Name): MONAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 SYCAMORE DR SUITE B
DECATUR GA
30030-1644
US

IV. Provider business mailing address

1014 SYCAMORE DR SUITE B
DECATUR GA
30030-1644
US

V. Phone/Fax

Practice location:
  • Phone: 404-299-1700
  • Fax: 404-299-1616
Mailing address:
  • Phone: 404-299-1700
  • Fax: 404-299-1616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number7967
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number7967
License Number StateGA

VIII. Authorized Official

Name: ALEX PHILLIP SCHULTZ
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C, MMSC
Phone: 504-239-3467