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General NPI Number Information
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NPI Number | 1730221649
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Entity Type | Organization
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Legal Business Name | COMMUNITY CARE MD
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Dates
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Enumeration Date | 02/14/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5019 LAVISTA RD
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City | TUCKER
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State | GA
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Zip | 30084-3541
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Country | US
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Telephone | 678-720-0422
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Fax | 678-720-0440
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Provider Business Mailing Address
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Address Line | 5019 LAVISTA RD
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City | TUCKER
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State | GA
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Zip | 30084-3541
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Country | US
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Telephone | 678-720-0422
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Fax | 678-720-0440
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Authorized Official
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Title or Position | DIRECTOR OF OP
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Name | MRS. JANE A LING
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Credential |
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Telephone | 678-720-0422
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 156221
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License Number State | GA
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