Healthcare Provider Details

I. General information

NPI: 1841876992
Provider Name (Legal Business Name): SYNERGISTIX UNIVERSAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3522 HABERSHAM AT NORTHLAKE STE B
TUCKER GA
30084-4009
US

IV. Provider business mailing address

3522 HABERSHAM AT NORTHLAKE STE B
TUCKER GA
30084-4009
US

V. Phone/Fax

Practice location:
  • Phone: 901-606-7966
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ALEXCIUS BRANCH
Title or Position: CEO
Credential:
Phone: 901-606-7966