Healthcare Provider Details

I. General information

NPI: 1043981517
Provider Name (Legal Business Name): ESTATE CLINICS BY CMG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 09/24/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 UPPER RIVERDALE RD SW
RIVERDALE GA
30274-2504
US

IV. Provider business mailing address

483 UPPER RIVERDALE RD SW STE F
RIVERDALE GA
30274-2579
US

V. Phone/Fax

Practice location:
  • Phone: 770-997-2160
  • Fax:
Mailing address:
  • Phone: 770-742-3883
  • Fax: 855-597-8504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KAYLENE MARTIN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 770-990-8212