Healthcare Provider Details

I. General information

NPI: 1730315870
Provider Name (Legal Business Name): FAMILY FIRST HEALTHCARE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 THORNTON RD
LITHIA SPRINGS GA
30122-2634
US

IV. Provider business mailing address

939 THORNTON RD
LITHIA SPRINGS GA
30122-2634
US

V. Phone/Fax

Practice location:
  • Phone: 770-739-1233
  • Fax: 770-948-4930
Mailing address:
  • Phone: 770-739-1233
  • Fax: 770-948-4930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number040613
License Number StateGA

VIII. Authorized Official

Name: DR. BRYAN D BLAKE
Title or Position: OWNER
Credential: M.D.
Phone: 770-739-1233