=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194128447
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROCARE MEDICAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2014
-----------------------------------------------------
Last Update Date | 10/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1395 S MARIETTA PKWY SE BLDG 100 SUITE 102
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30067-4440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-425-8700
-----------------------------------------------------
Fax | 770-425-8740
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1395 S MARIETTA PKWY SE BLDG 100 SUITE 102
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30067-4440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-425-8700
-----------------------------------------------------
Fax | 770-425-8740
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | CYNTHIA TATE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-428-8700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------