=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306247663
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HBISC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2014
-----------------------------------------------------
Last Update Date | 09/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3118 ESPLANADE CIR SW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30311-4221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-245-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 42944
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. OWEN HENDRICKS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 404-245-3900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------