Healthcare Provider Details

I. General information

NPI: 1902799695
Provider Name (Legal Business Name): ADVANCE COGNITIVE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2025
Last Update Date: 05/31/2025
Certification Date: 05/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4666 RANDALWOOD DR
STONE MOUNTAIN GA
30083-4350
US

IV. Provider business mailing address

4666 RANDALWOOD DR
STONE MOUNTAIN GA
30083-4350
US

V. Phone/Fax

Practice location:
  • Phone: 770-670-0540
  • Fax: 770-670-0540
Mailing address:
  • Phone: 770-670-0540
  • Fax: 770-670-0540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: AARON CLARK
Title or Position: OWNER
Credential: MD
Phone: 404-316-7159