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General NPI Number Information
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NPI Number | 1265136923
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Entity Type | Organization
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Legal Business Name | EXECUTIVE MEDICAL PRACTICE L.L.C.
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Dates
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Enumeration Date | 03/28/2023
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Last Update Date | 08/21/2023
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Provider Practice Location Address
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Address Line | 1455 BELLS FERRY RD STE 100
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City | MARIETTA
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State | GA
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Zip | 30066-6078
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Country | US
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Telephone | 770-421-8094
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Fax | 770-421-8096
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Provider Business Mailing Address
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Address Line | 1455 BELLS FERRY RD STE 100
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City | MARIETTA
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State | GA
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Zip | 30066-6078
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Country | US
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Telephone | 770-421-8094
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Fax | 770-421-8096
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Authorized Official
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Title or Position | CREDITIALING
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Name | RASHELLE FOX
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Credential |
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Telephone | 404-664-2997
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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