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General NPI Number Information
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NPI Number | 1043781420
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Entity Type | Organization
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Legal Business Name | CLARKSTON PRIMARY & URGENT CARE, LLC
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Dates
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Enumeration Date | 12/11/2018
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Last Update Date | 12/11/2018
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Provider Practice Location Address
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Address Line | 4600 E PONCE DE LEON AVE STE A
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City | CLARKSTON
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State | GA
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Zip | 30021-1839
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Country | US
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Telephone | 770-703-5408
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Fax | 877-779-5837
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Provider Business Mailing Address
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Address Line | 4600 E PONCE DE LEON AVE STE A
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City | CLARKSTON
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State | GA
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Zip | 30021-1839
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Country | US
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Telephone | 770-703-5408
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Fax | 877-779-5837
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | MS. ETSUBDENKE AREAYA
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Credential | FNP-C
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Telephone | 678-763-2247
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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