Healthcare Provider Details

I. General information

NPI: 1942453667
Provider Name (Legal Business Name): FRUIT OF MY WOMB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2008
Last Update Date: 10/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1836 CARROLLTON VILLA RICA HWY SUITE 308
VILLA RICA GA
30180-4916
US

IV. Provider business mailing address

1836 CARROLLTON VILLA RICA HWY SUITE 308
VILLA RICA GA
30180-4916
US

V. Phone/Fax

Practice location:
  • Phone: 770-783-9552
  • Fax: 770-783-9716
Mailing address:
  • Phone: 770-783-9552
  • Fax: 770-783-9716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: FRANCHESCA L HUSBAND
Title or Position: CEO
Credential: N/A
Phone: 770-783-9552