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General NPI Number Information
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NPI Number | 1235569344
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Entity Type | Organization
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Legal Business Name | MASTERPIECEWITHIN
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Dates
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Enumeration Date | 11/26/2013
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Last Update Date | 11/26/2013
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Provider Practice Location Address
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Address Line | 2164 HIDDEN GLEN DR SE
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City | MARIETTA
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State | GA
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Zip | 30067-8740
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Country | US
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Telephone | 678-913-9169
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Fax |
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Provider Business Mailing Address
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Address Line | 2164 HIDDEN GLEN DR SE
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City | MARIETTA
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State | GA
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Zip | 30067-8740
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Country | US
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Telephone | 678-913-9169
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. LORETTA JOHNSON MCCLEE
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Credential |
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Telephone | 678-913-9169
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | CL1230175
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License Number State | FL
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