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General NPI Number Information
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NPI Number | 1003356361
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Entity Type | Organization
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Legal Business Name | PROACTIVE PHYSICIANS OF MARIETTA, PC
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Dates
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Enumeration Date | 03/06/2017
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Last Update Date | 03/06/2017
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Provider Practice Location Address
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Address Line | 790 CHURCH ST NE SUITE 220
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City | MARIETTA
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State | GA
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Zip | 30060-7282
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Country | US
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Telephone | 678-753-9300
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Fax | 678-753-9300
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Provider Business Mailing Address
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Address Line | 790 CHURCH ST NE SUITE 220
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City | MARIETTA
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State | GA
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Zip | 30060-7282
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Country | US
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Telephone | 678-753-9300
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Fax | 678-753-9300
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Authorized Official
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Title or Position | COO
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Name | DR. RICHARD SCOTT MILLS
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Credential | MD
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Telephone | 678-794-2216
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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