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General NPI Number Information
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NPI Number | 1659930279
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Entity Type | Individual
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Provider Name | MR. SMART GUOBADIA
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Gender | Male
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Dates
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Enumeration Date | 06/07/2019
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Last Update Date | 06/07/2019
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Provider Practice Location Address
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Address Line | 1174 MCKENDREE CHURCH RD STE 100
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-6000
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Country | US
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Telephone | 470-338-1671
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Fax | 888-541-3996
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Provider Business Mailing Address
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Address Line | 1174 MCKENDREE CHURCH RD STE 100
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-6000
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Country | US
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Telephone | 470-338-1671
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Fax | 888-541-3996
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 067-R-1663
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License Number State | GA
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