Healthcare Provider Details

I. General information

NPI: 1790566271
Provider Name (Legal Business Name): DOMINIQUE CRAIN LOCUMS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6660 ROSWELL RD
SANDY SPRINGS GA
30328-3167
US

IV. Provider business mailing address

PO BOX 851982
MOBILE AL
36685-1982
US

V. Phone/Fax

Practice location:
  • Phone: 470-491-4328
  • Fax:
Mailing address:
  • Phone: 470-491-4328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. DOMINIQUE JUANITA CRAIN
Title or Position: FOUNDER/CEO/PHYSICIAN
Credential: MD
Phone: 470-491-4328