Healthcare Provider Details

I. General information

NPI: 1417996844
Provider Name (Legal Business Name): PROHBO - MARIETTA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 BELLS FERRY RD SUITE 100
MARIETTA GA
30066-6078
US

IV. Provider business mailing address

1455 BELLS FERRY RD SUITE 100
MARIETTA GA
30066-6078
US

V. Phone/Fax

Practice location:
  • Phone: 770-421-8094
  • Fax: 770-421-8096
Mailing address:
  • Phone: 770-421-8094
  • Fax: 770-421-8096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRISTOPHER GRANT
Title or Position: OWNER
Credential:
Phone: 770-421-8094