Healthcare Provider Details

I. General information

NPI: 1053012260
Provider Name (Legal Business Name): MOUNTAINS WOMEN'S CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 10/29/2024
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 SANDS PLACE SUITE 100
MARIETTA GA
30067
US

IV. Provider business mailing address

1611 SANDS PLACE SUITE 100
MARIETTA GA
30067
US

V. Phone/Fax

Practice location:
  • Phone: 678-944-8042
  • Fax: 678-293-7579
Mailing address:
  • Phone: 678-944-8042
  • Fax: 678-293-7579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: AMBER GLENN
Title or Position: OWNER, PHYSICIAN
Credential: M.D.
Phone: 678-944-8042