Healthcare Provider Details

I. General information

NPI: 1124066261
Provider Name (Legal Business Name): NORTHLAKE MULTISPECIALTY ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 MONTREAL RD SUITE 304
TUCKER GA
30084-6900
US

IV. Provider business mailing address

1459 MONTREAL RD SUITE 304
TUCKER GA
30084-6900
US

V. Phone/Fax

Practice location:
  • Phone: 770-908-4444
  • Fax: 770-908-4400
Mailing address:
  • Phone: 770-908-4444
  • Fax: 770-908-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHUCK LOCKE
Title or Position: VP
Credential:
Phone: 615-373-7604