Healthcare Provider Details

I. General information

NPI: 1316433477
Provider Name (Legal Business Name): PEACHTREE IMMEDIATE CARE FP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1495 LAFAYETTE PKWY
LAGRANGE GA
30241-2552
US

IV. Provider business mailing address

1275 HIGHWAY 54 W STE 201
FAYETTEVILLE GA
30214-4538
US

V. Phone/Fax

Practice location:
  • Phone: 706-884-7822
  • Fax: 706-884-7828
Mailing address:
  • Phone: 678-688-9685
  • Fax: 770-626-3791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18-10206
License Number StateGA

VIII. Authorized Official

Name: MRS. ANDREA MALIK-ROE
Title or Position: CFO
Credential:
Phone: 678-504-6392