Healthcare Provider Details

I. General information

NPI: 1912875402
Provider Name (Legal Business Name): MIXED MEDICAL MEDIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2025
Last Update Date: 10/27/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 HOSPITAL DR
STOCKBRIDGE GA
30281
US

IV. Provider business mailing address

1106 HOSPITAL DR
STOCKBRIDGE GA
30281
US

V. Phone/Fax

Practice location:
  • Phone: 678-902-9495
  • Fax: 678-815-1548
Mailing address:
  • Phone: 678-902-9495
  • Fax: 678-815-1548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: AARON FLETCHER
Title or Position: OWNER
Credential:
Phone: 678-902-9495