=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215278882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANNA MEDICAL & COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2013
-----------------------------------------------------
Last Update Date | 03/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305 CARROLLTON HIGHWAY
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30178
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-562-0777
-----------------------------------------------------
Fax | 770-562-0333
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 305 CARROLLTON HIGHWAY
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30178
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-562-0777
-----------------------------------------------------
Fax | 770-562-0333
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | CAROL E. BURTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-372-9280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 32101
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------