Healthcare Provider Details

I. General information

NPI: 1972036978
Provider Name (Legal Business Name): WATERWORKSNOW, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 E PARK PLACE BLVD SUITE 1800
STONE MOUNTAIN GA
30087-3453
US

IV. Provider business mailing address

PO BOX 370354
DECATUR GA
30037-0354
US

V. Phone/Fax

Practice location:
  • Phone: 678-558-6767
  • Fax:
Mailing address:
  • Phone: 678-558-6767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number48419
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number48419
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number48419
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number48419
License Number StateGA

VIII. Authorized Official

Name: DR. CYNTHIA GOODMAN
Title or Position: CEO/PRESIDENT
Credential: M.D.
Phone: 67855886767