Healthcare Provider Details

I. General information

NPI: 1205212917
Provider Name (Legal Business Name): TCWC LAWRENCEVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3157 SUGARLOAF PKWY STE 130
LAWRENCEVILLE GA
30045-9492
US

IV. Provider business mailing address

3157 SUGARLOAF PKWY STE 130
LAWRENCEVILLE GA
30045-9492
US

V. Phone/Fax

Practice location:
  • Phone: 678-828-4114
  • Fax: 404-855-4184
Mailing address:
  • Phone: 678-828-4114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberCHIR009505
License Number StateGA

VIII. Authorized Official

Name: AMBER BLUE
Title or Position: CONTRACTING MANAGER
Credential:
Phone: 636-978-0970