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General NPI Number Information
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NPI Number | 1255690475
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Entity Type | Organization
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Legal Business Name | MEDIC ONE LLC
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Dates
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Enumeration Date | 05/08/2012
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Last Update Date | 05/08/2012
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Provider Practice Location Address
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Address Line | 2621 SANDY PLAINS RD SUITE 304
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City | MARIETTA
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State | GA
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Zip | 30066-4267
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Country | US
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Telephone | 770-894-3167
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Fax | 770-575-0879
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Provider Business Mailing Address
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Address Line | PO BOX 670508
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City | MARIETTA
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State | GA
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Zip | 30066-0126
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Country | US
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Telephone | 770-894-3167
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Fax | 770-575-0879
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Authorized Official
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Title or Position | TREASURER
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Name | ADESUPO OSHIYOYE
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Credential |
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Telephone | 770-894-3167
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | 51736
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License Number State | GA
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