Healthcare Provider Details

I. General information

NPI: 1558411272
Provider Name (Legal Business Name): VILLA RICA OB GYN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 DALLAS HWY STE 301
VILLA RICA GA
30180-1263
US

IV. Provider business mailing address

690 DALLAS HWY STE 301
VILLA RICA GA
30180-1263
US

V. Phone/Fax

Practice location:
  • Phone: 770-456-3850
  • Fax: 770-456-3826
Mailing address:
  • Phone: 770-456-3850
  • Fax: 770-456-3826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBBI MACALUSO- PEARE
Title or Position: DIRECTOR OF FINANCIAL OPERATIONS
Credential:
Phone: 770-838-8544