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General NPI Number Information
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NPI Number | 1134422157
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Entity Type | Organization
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Legal Business Name | IMR IMMEDIATE CARE, LLC
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Dates
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Enumeration Date | 12/14/2010
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Last Update Date | 12/14/2010
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Provider Practice Location Address
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Address Line | 3540 DULUTH PARK LN SUITE 260
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City | DULUTH
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State | GA
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Zip | 30096-6674
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Country | US
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Telephone | 678-957-1043
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Fax | 678-957-1093
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Provider Business Mailing Address
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Address Line | 3540 DULUTH PARK LN SUITE 260
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City | DULUTH
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State | GA
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Zip | 30096-6674
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Country | US
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Telephone | 678-957-1043
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Fax | 678-957-1093
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | MRS. LISA MARIE CRANDALL
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Credential | APRN-FNP
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Telephone | 678-957-1043
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN173213 NP
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | GA042979
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License Number State | GA
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