Healthcare Provider Details

I. General information

NPI: 1093070773
Provider Name (Legal Business Name): FAMILY FIRST MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 CLEVELAND AVE STE 1
EAST POINT GA
30344-3417
US

IV. Provider business mailing address

1203 CLEVELAND AVE STE 1
EAST POINT GA
30344-3417
US

V. Phone/Fax

Practice location:
  • Phone: 404-209-1408
  • Fax: 404-209-1411
Mailing address:
  • Phone: 404-209-1408
  • Fax: 404-209-1411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number08064086
License Number StateGA

VIII. Authorized Official

Name: MRS. MARIA PILAR MOREIRA
Title or Position: OWNER
Credential: CEO
Phone: 404-209-1408