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General NPI Number Information
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NPI Number | 1336651702
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Entity Type | Organization
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Legal Business Name | CLINICA FAMILIAR Y PRENATAL
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Dates
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Enumeration Date | 10/25/2017
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Last Update Date | 10/25/2017
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Provider Practice Location Address
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Address Line | 155 MEDICAL WAY STE B
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City | RIVERDALE
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State | GA
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Zip | 30274-4940
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Country | US
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Telephone | 678-755-5334
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Fax | 404-529-4430
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Provider Business Mailing Address
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Address Line | 155 MEDICAL WAY STE B
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City | RIVERDALE
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State | GA
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Zip | 30274-4940
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Country | US
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Telephone | 678-755-5334
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Fax | 404-529-4430
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | BRIDGETTE HANNIGAN
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Credential | RCS
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Telephone | 678-755-5334
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | RN120872
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License Number State | GA
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