Healthcare Provider Details

I. General information

NPI: 1043495427
Provider Name (Legal Business Name): ADVANCED MEDICAL CLINICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2008
Last Update Date: 01/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5499 JONESBORO RD
LAKE CITY GA
30260-3553
US

IV. Provider business mailing address

5499 JONESBORO RD
LAKE CITY GA
30260-3553
US

V. Phone/Fax

Practice location:
  • Phone: 404-363-6460
  • Fax: 404-363-4348
Mailing address:
  • Phone: 404-363-6460
  • Fax: 404-363-4348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number047279
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR002353
License Number StateGA

VIII. Authorized Official

Name: MS. LISA ROCHE
Title or Position: OFFICE MANAGER
Credential:
Phone: 404-363-6460