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General NPI Number Information
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NPI Number | 1457737926
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Entity Type | Organization
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Legal Business Name | MC JO LLC
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Dates
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Enumeration Date | 08/06/2015
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Last Update Date | 08/06/2015
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Provider Practice Location Address
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Address Line | 4505 RIVER STONE TRL
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City | DOUGLASVILLE
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State | GA
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Zip | 30135-8678
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Country | US
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Telephone | 678-836-9799
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Fax |
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Provider Business Mailing Address
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Address Line | 4505 RIVER STONE TRL
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City | DOUGLASVILLE
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State | GA
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Zip | 30135-8678
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Country | US
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Telephone | 678-836-9799
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | DR. OBINNA OKECHUKWU OLOWU
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Credential |
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Telephone | 678-836-9799
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 048-R-1373
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License Number State | GA
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