Healthcare Provider Details

I. General information

NPI: 1174776314
Provider Name (Legal Business Name): LAFAYETTE MEDICAL AND ALTERNATIVE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2008
Last Update Date: 10/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 HUGH HOWELL RD 320
TUCKER GA
30084-4723
US

IV. Provider business mailing address

4500 HUGH HOWELL RD 320
TUCKER GA
30084-4723
US

V. Phone/Fax

Practice location:
  • Phone: 770-621-9405
  • Fax: 770-621-9433
Mailing address:
  • Phone: 770-621-9405
  • Fax: 770-621-9433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number041157352
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number04115352
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number041157352
License Number StateGA

VIII. Authorized Official

Name: MRS. CATHRYN PARKMAN
Title or Position: TRREATMENT
Credential: LISCENSE NURSE
Phone: 770-621-9405