Healthcare Provider Details

I. General information

NPI: 1841800679
Provider Name (Legal Business Name): OM PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 WESTBROOK RD BLDG A
SUWANEE GA
30024-4987
US

IV. Provider business mailing address

220 NEWPORT FAIRWAY
ALPHARETTA GA
30005-7825
US

V. Phone/Fax

Practice location:
  • Phone: 470-416-3424
  • Fax:
Mailing address:
  • Phone: 470-416-3424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KINJAL AMIT KACHALIA
Title or Position: DIRECTOR
Credential: MBBS MBA
Phone: 470-416-3424