Healthcare Provider Details

I. General information

NPI: 1154080786
Provider Name (Legal Business Name): ASTHMA ALLERGY AND IMMUNOLOGY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 N PARK TRL
STOCKBRIDGE GA
30281-7373
US

IV. Provider business mailing address

756 PENINSULA OVERLOOK
HAMPTON GA
30228-6062
US

V. Phone/Fax

Practice location:
  • Phone: 678-489-7901
  • Fax: 833-559-0864
Mailing address:
  • Phone: 678-489-7901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HOSAMANE S PRABHAKARA
Title or Position: PRESIDENT
Credential: MD
Phone: 678-489-7901