Healthcare Provider Details

I. General information

NPI: 1821183237
Provider Name (Legal Business Name): COOSA PROCEDURE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 01/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 RIVERBEND DR SW STE 120
ROME GA
30161-6019
US

IV. Provider business mailing address

PO BOX 80883
ATHENS GA
30608-0883
US

V. Phone/Fax

Practice location:
  • Phone: 706-378-1202
  • Fax: 706-378-1204
Mailing address:
  • Phone: 706-549-8114
  • Fax: 706-549-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number057288
License Number StateGA

VIII. Authorized Official

Name: DR. DAWNETTA JANENE HOLLADAY
Title or Position: CEO
Credential: M.D.
Phone: 706-549-8114