Healthcare Provider Details

I. General information

NPI: 1508134156
Provider Name (Legal Business Name): EDUCATION SYSTEM MANAGEMENT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 HIGHWAY 138
RIVERDALE GA
30274
US

IV. Provider business mailing address

1115 MOUNT ZION RD SUITE C
MORROW GA
30260-2266
US

V. Phone/Fax

Practice location:
  • Phone: 770-742-0265
  • Fax: 770-742-0862
Mailing address:
  • Phone: 770-742-0265
  • Fax: 770-742-0862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW003727
License Number StateGA

VIII. Authorized Official

Name: DR. CARROLL BRADDY
Title or Position: CEO
Credential: M.D.,MBA
Phone: 770-892-5284