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General NPI Number Information
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NPI Number | 1366712846
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Entity Type | Organization
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Legal Business Name | WATERFORD MEDICAL CLINIC
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Dates
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Enumeration Date | 12/30/2011
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Last Update Date | 12/30/2011
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Provider Practice Location Address
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Address Line | 3069 AMWILER RD SUITE TWO
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City | ATLANTA
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State | GA
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Zip | 30360-2825
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Country | US
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Telephone | 678-969-9920
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Fax | 678-969-9919
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Provider Business Mailing Address
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Address Line | 3069 AMWILER RD SUITE 2
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City | ATLANTA
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State | GA
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Zip | 30360-2825
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Country | US
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Telephone | 678-969-9920
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Fax | 678-969-9919
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. JOHN SALINAS
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Credential |
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Telephone | 404-992-9130
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 038600
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License Number State | GA
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