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General NPI Number Information
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NPI Number | 1639552649
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Entity Type | Organization
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Legal Business Name | SUPREME HEALTHCARE OB/GYN LLC
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Dates
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Enumeration Date | 07/08/2015
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Last Update Date | 07/08/2015
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Provider Practice Location Address
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Address Line | 5536 FLAT SHOALS PKWY SUITE A
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City | DECATUR
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State | GA
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Zip | 30034-5408
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Country | US
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Telephone | 678-518-9691
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Fax | 678-518-9692
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Provider Business Mailing Address
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Address Line | 5536 FLAT SHOALS PKWY SUITE A
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City | DECATUR
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State | GA
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Zip | 30034-5408
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Country | US
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Telephone | 678-518-9691
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Fax | 678-518-9692
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Authorized Official
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Title or Position | ASSISTANT PRACTICE MANAGER
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Name | MS. KIMAR DUNN
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Credential |
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Telephone | 678-518-9691
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 57621
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License Number State | GA
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