Healthcare Provider Details

I. General information

NPI: 1033132998
Provider Name (Legal Business Name): WMC TYRONE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 HANDLEY RD
TYRONE GA
30290-2178
US

IV. Provider business mailing address

190 HANDLEY RD SUITE A
TYRONE GA
30290-2178
US

V. Phone/Fax

Practice location:
  • Phone: 770-997-5714
  • Fax: 770-997-2810
Mailing address:
  • Phone: 770-997-5714
  • Fax: 770-997-2810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH MOORE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 770-997-5714