Healthcare Provider Details

I. General information

NPI: 1871759233
Provider Name (Legal Business Name): JEANNIE-IN-A-BOTTLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 HOWELL FERRY RD
DULUTH GA
30096-3178
US

IV. Provider business mailing address

1343 CANTON RD STE C
MARIETTA GA
30066-6079
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-6800
  • Fax: 678-312-5622
Mailing address:
  • Phone: 866-214-8600
  • Fax: 678-888-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number041517
License Number StateGA

VIII. Authorized Official

Name: MS. JEANNIE M BLOM
Title or Position: CEO
Credential: M.D.
Phone: 404-849-3443