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General NPI Number Information
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NPI Number | 1356616338
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Entity Type | Organization
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Legal Business Name | ELEVEN 11 MEDICAL MANAGEMENT, LLC
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Dates
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Enumeration Date | 03/09/2012
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Last Update Date | 03/09/2012
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Provider Practice Location Address
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Address Line | 438 HENRY FORD II AVE
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City | HAPEVILLE
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State | GA
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Zip | 30354-1622
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Country | US
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Telephone | 678-235-2401
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Fax | 678-235-2403
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Provider Business Mailing Address
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Address Line | 438 HENRY FORD II AVE
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City | HAPEVILLE
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State | GA
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Zip | 30354-1622
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Country | US
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Telephone | 678-235-2401
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Fax | 678-235-2403
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. CYNTHIA TATE
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Credential |
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Telephone | 678-235-2401
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207KA0200X
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Taxonomy Name | Allergy Physician
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License Number |
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License Number State |
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