Healthcare Provider Details

I. General information

NPI: 1154431732
Provider Name (Legal Business Name): NORTH FAYETTE FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 HIGHWAY 314 STE B
FAYETTEVILLE GA
30214-7813
US

IV. Provider business mailing address

290 HIGHWAY 314 STE B
FAYETTEVILLE GA
30214-7813
US

V. Phone/Fax

Practice location:
  • Phone: 770-716-8228
  • Fax:
Mailing address:
  • Phone: 770-716-8228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License Number33753
License Number StateGA

VIII. Authorized Official

Name: KELVIN D WHITE
Title or Position: OWNER
Credential: MD
Phone: 770-716-8228