=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164614194
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIME COMMUNITY HEALTH GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2007
-----------------------------------------------------
Last Update Date | 12/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2085 METROPOLITAN PKWY SW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30315-5926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-505-7500
-----------------------------------------------------
Fax | 404-505-1238
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3435 KINGSBORO RD NE 1804
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30326-1344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-505-7500
-----------------------------------------------------
Fax | 404-846-5561
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRATOR
-----------------------------------------------------
Name | DR. VERNICE RENEE ROBINSON
-----------------------------------------------------
Credential | D. C.
-----------------------------------------------------
Telephone | 404-505-7500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4943
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------