=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124792106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINI-MED CLINIC OF NORTH GEORGIA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2021
-----------------------------------------------------
Last Update Date | 08/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5113 HOLLY SPRINGS PARKWAY
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-331-3544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5113 HOLLY SPRINGS PARKWAY
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-398-9697
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | MS. SOPHIA KENNEDY
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 678-398-9697
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------