Healthcare Provider Details

I. General information

NPI: 1275708786
Provider Name (Legal Business Name): SN GWINETT COUNTY RADIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2094 MCGEE RD
SNELLVILLE GA
30078-2911
US

IV. Provider business mailing address

53 PERIMETER CTR E SUITE 500
ATLANTA GA
30346-2294
US

V. Phone/Fax

Practice location:
  • Phone: 770-979-3705
  • Fax: 770-979-3706
Mailing address:
  • Phone: 770-682-2080
  • Fax: 678-587-9275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: TAMMIE LAVISCOUNT
Title or Position: CONTRACT ANALYST
Credential:
Phone: 770-682-2080