Healthcare Provider Details

I. General information

NPI: 1437346509
Provider Name (Legal Business Name): FAMILY PRACTICE CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

696 GRAYSON HWY
LAWRENCEVILLE GA
30046-6372
US

IV. Provider business mailing address

696 GRAYSON HWY
LAWRENCEVILLE GA
30046-6372
US

V. Phone/Fax

Practice location:
  • Phone: 770-963-0927
  • Fax: 770-963-9772
Mailing address:
  • Phone: 770-963-0927
  • Fax: 770-963-9772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20001
License Number StateGA

VIII. Authorized Official

Name: DR. SHEILA JEANNE SMITH
Title or Position: OWNER
Credential: DO
Phone: 770-963-0927