Healthcare Provider Details

I. General information

NPI: 1740640150
Provider Name (Legal Business Name): COMMUNITY CLINICS OF GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2016
Last Update Date: 02/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 WASHINGTON AVE
GAINESVILLE GA
30501-4135
US

IV. Provider business mailing address

3 WASHINGTON AVE
GAINESVILLE GA
30501-4135
US

V. Phone/Fax

Practice location:
  • Phone: 678-707-8539
  • Fax: 678-989-1605
Mailing address:
  • Phone: 678-707-8539
  • Fax: 678-989-1605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number75206
License Number StateGA

VIII. Authorized Official

Name: DR. JOHN JAMES DI BLASI
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 904-482-9673