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General NPI Number Information
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NPI Number | 1053691311
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Entity Type | Organization
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Legal Business Name | EXPRESS MEDICAL, LLC
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Dates
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Enumeration Date | 08/18/2011
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Last Update Date | 08/25/2011
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Provider Practice Location Address
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Address Line | 931 LOWER FAYETTEVILLE RD SUITE J
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City | NEWNAN
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State | GA
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Zip | 30263-5790
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Country | US
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Telephone | 770-715-9391
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Fax |
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Provider Business Mailing Address
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Address Line | 931 LOWER FAYETTEVILLE RD SUITE J
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City | NEWNAN
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State | GA
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Zip | 30263-5790
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Country | US
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Telephone | 770-715-9391
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MR. REGINALD WT PHILIP
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Credential |
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Telephone | 678-263-6713
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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 | 142462
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License Number State | GA
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