Healthcare Provider Details

I. General information

NPI: 1982033155
Provider Name (Legal Business Name): PEACHTREE ORTHOPAEDIC CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3870 PLEASANT HILL RD SUITE 1-MOD B
DULUTH GA
30096-4807
US

IV. Provider business mailing address

3870 PLEASANT HILL RD SUITE 1-MOD B
DULUTH GA
30096-4807
US

V. Phone/Fax

Practice location:
  • Phone: 404-355-0743
  • Fax: 404-355-2136
Mailing address:
  • Phone: 404-355-0743
  • Fax: 404-355-2136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARIA SANDERS
Title or Position: CFO
Credential: CPA
Phone: 404-355-0743