Healthcare Provider Details

I. General information

NPI: 1417397662
Provider Name (Legal Business Name): RIESA JOHN GREATER ATLANTA URGENT CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 SAMMY MCGHEE BLVD SUITE 101
JASPER GA
30143-7703
US

IV. Provider business mailing address

91 SAMMY MCGHEE BLVD SUITE 101
JASPER GA
30143-7703
US

V. Phone/Fax

Practice location:
  • Phone: 706-253-3341
  • Fax: 706-253-3361
Mailing address:
  • Phone: 706-253-3341
  • Fax: 706-253-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number29
License Number StateGA

VIII. Authorized Official

Name: ERNEST AMUKAMARA
Title or Position: MANAGER
Credential: NP
Phone: 706-253-3341