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General NPI Number Information
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NPI Number | 1750721221
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Entity Type | Organization
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Legal Business Name | INTERNATIONAL COMMUNITY MEDICAL NETWORK, LLC
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Dates
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Enumeration Date | 06/28/2013
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Last Update Date | 06/28/2013
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Provider Practice Location Address
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Address Line | 1900 WINDSOR DR SW
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City | ATLANTA
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State | GA
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Zip | 30311-4414
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Country | US
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Telephone | 559-455-3934
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Fax |
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Provider Business Mailing Address
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Address Line | 1900 WINDSOR DR SW
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City | ATLANTA
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State | GA
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Zip | 30311-4414
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Country | US
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Telephone | 559-455-3934
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KWAME MAKINI
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Credential |
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Telephone | 559-455-3934
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2083P0901X
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Taxonomy Name | Public Health & General Preventive Medicine Physician
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License Number |
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License Number State |
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