Healthcare Provider Details

I. General information

NPI: 1023134640
Provider Name (Legal Business Name): LOCUST GROVE ENDO CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4865 BILL GARDNER PARKWAY
LOCUST GROVE GA
30248
US

IV. Provider business mailing address

4865 BILL GARDNER PARKWAY
LOCUST GROVE GA
30248
US

V. Phone/Fax

Practice location:
  • Phone: 770-692-0100
  • Fax:
Mailing address:
  • Phone: 770-692-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ARUNA R PRAKASH
Title or Position: ADMINISTRATOR
Credential: B.SC
Phone: 770-692-0100