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General NPI Number Information
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NPI Number | 1619101813
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Entity Type | Organization
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Legal Business Name | CLINICA MEDICA FAMILIAR, LLP
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Dates
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Enumeration Date | 05/04/2009
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Last Update Date | 05/04/2009
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Provider Practice Location Address
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Address Line | 189 MEDICAL WAY SUITE B
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City | RIVERDALE
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State | GA
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Zip | 30274-4905
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Country | US
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Telephone | 770-996-9681
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Fax | 770-996-9683
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Provider Business Mailing Address
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Address Line | 189 MEDICAL WAY SUITE B
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City | RIVERDALE
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State | GA
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Zip | 30274-4905
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Country | US
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Telephone | 770-996-9681
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Fax | 770-996-9683
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MR. JACK PATRICK DOURRON
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Credential |
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Telephone | 770-996-9681
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 027722
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 014308
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License Number State | GA
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