Healthcare Provider Details

I. General information

NPI: 1538414164
Provider Name (Legal Business Name): FOREST PARK PROFESSIONAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 FOREST PKWY
FOREST PARK GA
30297-6144
US

IV. Provider business mailing address

541 FOREST PKWY
FOREST PARK GA
30297-6144
US

V. Phone/Fax

Practice location:
  • Phone: 954-608-3737
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: VINCE MONTELIONE
Title or Position: MANAGER
Credential:
Phone: 954-608-3737