Healthcare Provider Details

I. General information

NPI: 1982288536
Provider Name (Legal Business Name): GEORGIA HEALTH CLINICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11040 CRABAPPLE RD STE A
ROSWELL GA
30075-2457
US

IV. Provider business mailing address

11040 CRABAPPLE RD STE A
ROSWELL GA
30075-2457
US

V. Phone/Fax

Practice location:
  • Phone: 678-522-6315
  • Fax:
Mailing address:
  • Phone: 678-522-6315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: GREG PRIDGEN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 678-203-1323