=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023887684
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENKE INVESTMENT, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/25/2023
-----------------------------------------------------
Last Update Date | 02/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12195 HIGHWAY 92 STE 144
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30188-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-540-7827
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 CORRIGAN TRCE
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269-3287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-595-4700
-----------------------------------------------------
Fax | 770-679-8752
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VANESSA MENKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 925-595-4700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RB0002X
-----------------------------------------------------
Taxonomy Name | Obesity Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------