Healthcare Provider Details

I. General information

NPI: 1063853364
Provider Name (Legal Business Name): CMO OF GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6728 CHESEPEAKE TRL
REX GA
30273-2229
US

IV. Provider business mailing address

PO BOX 258
MORROW GA
30260-0258
US

V. Phone/Fax

Practice location:
  • Phone: 404-664-6183
  • Fax:
Mailing address:
  • Phone: 404-664-6183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberRN163373
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberRN163373
License Number StateGA

VIII. Authorized Official

Name: MS. ALCENIA COLEMAN
Title or Position: COO
Credential: RN
Phone: 404-664-6183