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General NPI Number Information
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NPI Number | 1467572321
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Entity Type | Organization
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Legal Business Name | BETHEL GROUP OF GEORGIA INC
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Dates
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Enumeration Date | 04/01/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2870 PEACHTREE RD NW SUITE 919
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City | ATLANTA
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State | GA
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Zip | 30305-2918
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Country | US
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Telephone | 404-735-9844
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Fax | 404-355-4669
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Provider Business Mailing Address
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Address Line | 2870 PEACHTREE RD NW SUITE 919
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City | ATLANTA
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State | GA
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Zip | 30305-2918
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Country | US
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Telephone | 404-735-9844
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Fax | 404-355-4669
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. JORGE JUAN BACALLAO
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Credential |
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Telephone | 404-735-9844
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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 | 139625LGB
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License Number State | GA
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