Healthcare Provider Details

I. General information

NPI: 1366969560
Provider Name (Legal Business Name): ALLERGY CONSULTING GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 08/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5752B BUFORD HWY NE
DORAVILLE GA
30340-1207
US

IV. Provider business mailing address

PO BOX 501741
ATLANTA GA
31150-1741
US

V. Phone/Fax

Practice location:
  • Phone: 770-652-3667
  • Fax: 770-573-3611
Mailing address:
  • Phone: 770-652-3667
  • Fax: 770-573-3611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK REZNIK
Title or Position: MANAGER
Credential:
Phone: 770-652-3667