Healthcare Provider Details

I. General information

NPI: 1841955937
Provider Name (Legal Business Name): IDEAL MEDCLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6572 RIVER PARK DR STE 102
RIVERDALE GA
30274-2214
US

IV. Provider business mailing address

6572 RIVER PARK DR STE 102
RIVERDALE GA
30274-2214
US

V. Phone/Fax

Practice location:
  • Phone: 770-629-2296
  • Fax:
Mailing address:
  • Phone: 770-629-2296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MELISSA SALCIDO
Title or Position: CFO
Credential:
Phone: 678-314-7235