Healthcare Provider Details

I. General information

NPI: 1689036949
Provider Name (Legal Business Name): RELIANCE FAMILY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 HUNTINGTON PLACE CT
MCDONOUGH GA
30253-8651
US

IV. Provider business mailing address

345 HUNTINGTON PLACE CT
MCDONOUGH GA
30253-8651
US

V. Phone/Fax

Practice location:
  • Phone: 678-272-7280
  • Fax: 678-610-6025
Mailing address:
  • Phone: 678-272-7280
  • Fax: 678-610-6025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number053715
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number053715
License Number StateGA

VIII. Authorized Official

Name: MS. DONNA PEARSON
Title or Position: OM
Credential: RMA,CPC
Phone: 770-377-8874