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General NPI Number Information
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NPI Number | 1356797666
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Entity Type | Organization
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Legal Business Name | MAT GEORGIA, LLC
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Dates
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Enumeration Date | 05/05/2016
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Last Update Date | 05/05/2016
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Provider Practice Location Address
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Address Line | 335 ROSELANE ST NW SUITE 203
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City | MARIETTA
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State | GA
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Zip | 30060-7902
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Country | US
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Telephone | 818-212-4659
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Fax |
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Provider Business Mailing Address
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Address Line | 1290 KENNESTONE CIR SUITE A112
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City | MARIETTA
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State | GA
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Zip | 30066-6009
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | VICTOR ALFONSO
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Credential |
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Telephone | 818-212-4659
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RA0401X
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Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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