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General NPI Number Information
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NPI Number | 1083986681
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Entity Type | Organization
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Legal Business Name | BRIDGEMILL FAMILY HEALTHCARE, LLC
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Dates
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Enumeration Date | 01/30/2012
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Last Update Date | 01/30/2012
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Provider Practice Location Address
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Address Line | 3760 SIXES RD SUITE 120
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City | CANTON
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State | GA
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Zip | 30114-8192
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Country | US
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Telephone | 770-704-4580
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Fax |
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Provider Business Mailing Address
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Address Line | 3760 SIXES RD SUITE 120
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City | CANTON
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State | GA
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Zip | 30114-8192
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Country | US
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Telephone | 770-704-4580
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Fax |
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Authorized Official
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Title or Position | ATTORNEY
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Name | MR. OTIS BONNER III
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Credential |
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Telephone | 770-866-5488
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State | GA
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Taxonomy #3
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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 | GA
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