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General NPI Number Information
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NPI Number | 1497951081
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Entity Type | Organization
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Legal Business Name | AMARC MEDICAL & RESEARCH CLINIC
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Dates
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Enumeration Date | 06/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1309 LAKEWOOD AVE SE
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City | ATLANTA
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State | GA
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Zip | 30315-2312
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Country | US
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Telephone | 404-838-0904
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Fax | 770-446-2686
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Provider Business Mailing Address
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Address Line | PO BOX 767
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City | FAIRBURN
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State | GA
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Zip | 30213-0767
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Country | US
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Telephone | 404-838-0904
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Fax | 770-446-2686
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | BONA ILONZO
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Credential |
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Telephone | 404-838-0904
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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