Healthcare Provider Details

I. General information

NPI: 1346784055
Provider Name (Legal Business Name): OLAN COMPREHENSIVE HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2169 LAWRENCEVILLE HWY
LAWRENCEVILLE GA
30044-7710
US

IV. Provider business mailing address

2169 LAWRENCEVILLE HWY
LAWRENCEVILLE GA
30044-7710
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-3700
  • Fax: 770-962-8063
Mailing address:
  • Phone: 770-962-3700
  • Fax: 770-962-8063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number53032
License Number StateGA

VIII. Authorized Official

Name: MRS. ANDREE NECOLE MATTHEWS
Title or Position: BILLING MANAGER
Credential:
Phone: 678-613-2971