Healthcare Provider Details

I. General information

NPI: 1053787358
Provider Name (Legal Business Name): CLINICA UNION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2015
Last Update Date: 08/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 HOLCOMB BRIDGE RD STE 200
ROSWELL GA
30076-1900
US

IV. Provider business mailing address

3369 BUFORD HWY NE SUITE 810
BROOKHAVEN GA
30329-3722
US

V. Phone/Fax

Practice location:
  • Phone: 770-992-4455
  • Fax:
Mailing address:
  • Phone: 404-321-4692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIO RIVERA
Title or Position: CEO
Credential: M.D
Phone: 404-321-4692