Healthcare Provider Details

I. General information

NPI: 1215171459
Provider Name (Legal Business Name): FAMILYCARE MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 04/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6685 MERCHANTS WAY SUITE B
MORROW GA
30260-2342
US

IV. Provider business mailing address

PO BOX 783
REX GA
30273-0783
US

V. Phone/Fax

Practice location:
  • Phone: 770-968-1997
  • Fax: 770-968-1918
Mailing address:
  • Phone: 770-968-1997
  • Fax: 770-968-1918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number054039
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number054039
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number054039
License Number StateGA

VIII. Authorized Official

Name: DR. VICTORIA H. THEDFORD
Title or Position: OWNER
Credential: M.D.
Phone: 770-968-1997