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General NPI Number Information
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NPI Number | 1720569403
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Entity Type | Organization
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Legal Business Name | PHOENIX CLINIC AND AFTERHOUR CARE
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Dates
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Enumeration Date | 08/22/2018
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Last Update Date | 08/22/2018
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Provider Practice Location Address
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Address Line | 2795 MAIN ST W # 21
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City | SNELLVILLE
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State | GA
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Zip | 30078-3164
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Country | US
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Telephone | 678-386-2929
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Fax |
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Provider Business Mailing Address
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Address Line | 5858 SILVER RIDGE DR
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City | STONE MOUNTAIN
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State | GA
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Zip | 30087-2322
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Country | US
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Telephone | 678-386-2929
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARIE LIGHTBOURNE
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Credential | MD
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Telephone | 678-386-2929
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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 | 060359
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License Number State | GA
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