Healthcare Provider Details

I. General information

NPI: 1770246613
Provider Name (Legal Business Name): MACAGAIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 SAVANNAH PL
DULUTH GA
30096-4898
US

IV. Provider business mailing address

3650 SAVANNAH PL
DULUTH GA
30096-4898
US

V. Phone/Fax

Practice location:
  • Phone: 206-866-7605
  • Fax:
Mailing address:
  • Phone: 678-386-1625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name: KHALID ANSARI
Title or Position: PRESIDENT
Credential:
Phone: 678-386-1625