Healthcare Provider Details

I. General information

NPI: 1205334620
Provider Name (Legal Business Name): GEORGIA PRENATAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 INDIAN TRAIL LILBURN RD NW
LILBURN GA
30047-1721
US

IV. Provider business mailing address

950 INDIAN TRAIL LILBURN RD NW
LILBURN GA
30047-1721
US

V. Phone/Fax

Practice location:
  • Phone: 470-545-2131
  • Fax: 770-809-5154
Mailing address:
  • Phone: 470-545-2131
  • Fax: 770-809-5154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number58124
License Number StateGA

VIII. Authorized Official

Name: MRS. VALENCIA W FLOURNOY
Title or Position: MEDICAL CONSULTANT
Credential:
Phone: 404-579-2188