Healthcare Provider Details

I. General information

NPI: 1790739357
Provider Name (Legal Business Name): AOA GWINNETT OPERATING COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

698 DULUTH HWY
LAWRENCEVILLE GA
30046
US

IV. Provider business mailing address

3330 PRESTON RIDGE RD SUITE 300
ALPHARETTA GA
30005-4508
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-8888
  • Fax: 770-963-7447
Mailing address:
  • Phone: 770-350-0126
  • Fax: 770-350-6637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DALE LYNN MCCORD
Title or Position: CEO
Credential: MD
Phone: 770-350-0126