Healthcare Provider Details

I. General information

NPI: 1215840350
Provider Name (Legal Business Name): BRIAN PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3070 BUSINESS PARK DR STE B
NORCROSS GA
30071-1428
US

IV. Provider business mailing address

4170 SPRINGLAKE CIR
BUFORD GA
30519-3942
US

V. Phone/Fax

Practice location:
  • Phone: 770-884-1050
  • Fax:
Mailing address:
  • Phone: 770-598-2692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: