Healthcare Provider Details

I. General information

NPI: 1164045548
Provider Name (Legal Business Name): MY CHRONIC CARE MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 10/20/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 WHITLOCK PL SW STE 101
MARIETTA GA
30064-3176
US

IV. Provider business mailing address

PO BOX 2198
KENNESAW GA
30156-9102
US

V. Phone/Fax

Practice location:
  • Phone: 770-635-7166
  • Fax: 404-591-8002
Mailing address:
  • Phone: 770-635-7166
  • Fax: 404-591-8002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MAURICE L WOODARD
Title or Position: PRESIDENT
Credential:
Phone: 404-309-5200