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General NPI Number Information
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NPI Number | 1184819930
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Entity Type | Organization
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Legal Business Name | EAST COBB PODIATRY SURGERY CENTER, LLC
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Dates
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Enumeration Date | 09/13/2007
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Last Update Date | 06/28/2012
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Provider Practice Location Address
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Address Line | 4439 ROSWELL RD
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City | MARIETTA
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State | GA
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Zip | 30062-6452
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Country | US
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Telephone | 770-977-8221
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Fax | 770-977-8222
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Provider Business Mailing Address
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Address Line | 4439 ROSWELL RD
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City | MARIETTA
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State | GA
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Zip | 30062-6452
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Country | US
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Telephone | 770-977-8221
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Fax | 770-977-8222
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. MARK R LIGHT
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Credential | D.P.M.
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Telephone | 770-977-8221
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 11C0001132
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License Number State | GA
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