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General NPI Number Information
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NPI Number | 1235415696
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Entity Type | Organization
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Legal Business Name | NORTHLAKE MEDICAL & WELLNESS CENTER
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Dates
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Enumeration Date | 10/31/2011
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Last Update Date | 10/31/2011
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Provider Practice Location Address
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Address Line | 2244 HENDERSON MILL RD NE SUITE 108
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City | ATLANTA
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State | GA
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Zip | 30345-2760
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Country | US
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Telephone | 678-551-7810
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Fax | 678-551-7815
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Provider Business Mailing Address
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Address Line | 2244 HENDERSON MILL RD NE SUITE 108
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City | ATLANTA
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State | GA
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Zip | 30345-2760
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Country | US
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Telephone | 678-551-7810
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Fax | 678-551-7815
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MS. MARY CAMMACK
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Credential |
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Telephone | 678-551-7810
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 036281
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License Number State | GA
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