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General NPI Number Information
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NPI Number | 1447558010
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Entity Type | Organization
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Legal Business Name | MOFAZZAL SURAIYA LLC
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Dates
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Enumeration Date | 03/07/2011
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Last Update Date | 03/07/2011
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Provider Practice Location Address
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Address Line | 1015 OMAHA DR
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City | NORCROSS
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State | GA
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Zip | 30093-4967
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Country | US
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Telephone | 404-587-8500
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Fax | 770-939-5682
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Provider Business Mailing Address
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Address Line | 2775 CRUSE RD SUITE 101
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City | LAWRENCEVILLE
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State | GA
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Zip | 30044-7140
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Country | US
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Telephone | 404-587-8500
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Fax | 770-939-5682
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Authorized Official
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Title or Position | OWNER
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Name | JAMIL IMRAN
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Credential | M.D.
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Telephone | 404-587-8500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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