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General NPI Number Information
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NPI Number | 1093108763
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Entity Type | Organization
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Legal Business Name | MYSTIC MEDICAL, LLC
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Dates
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Enumeration Date | 03/05/2015
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Last Update Date | 03/25/2025
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Provider Practice Location Address
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Address Line | 5555 GLENRIDGE CONNECTOR SUITE 200
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City | ATLANTA
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State | GA
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Zip | 30342-4759
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Country | US
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Telephone | 404-351-0055
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Fax |
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Provider Business Mailing Address
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Address Line | 5555 GLENRIDGE CONNECTOR SUITE 200
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City | ATLANTA
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State | GA
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Zip | 30342-4759
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ADMIN
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Name | AMANDA DYKES
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Credential |
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Telephone | 404-351-0055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number |
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License Number State |
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