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General NPI Number Information
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NPI Number | 1710483409
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Entity Type | Organization
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Legal Business Name | PROVIDENCE NEUROPSYCHIATRIC HEALTH, LLC
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Dates
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Enumeration Date | 04/02/2018
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Last Update Date | 10/30/2022
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Provider Practice Location Address
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Address Line | 709 BREEDLOVE DR
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City | MONROE
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State | GA
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Zip | 30655-2055
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Country | US
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Telephone | 717-460-8885
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Fax |
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Provider Business Mailing Address
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Address Line | 2483 HERITAGE VILLAGE SUITE 16 - 490
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City | SNELLVILLE
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State | GA
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Zip | 30078
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Country | US
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Telephone | 470-610-0644
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Fax | 470-610-0650
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Authorized Official
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Title or Position | OWNER
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Name | DR. ADEWUMI ADEBOMOJO
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Credential | MD
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Telephone | 717-460-8885
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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