=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780327346
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUALITY HEALTH SOURCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2022
-----------------------------------------------------
Last Update Date | 10/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6116 MABLETON PKWY SW STE 136
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-4305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-878-2997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6116 MABLETON PKWY SW STE 136
-----------------------------------------------------
City | MABLETON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30126-4305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-324-8009
-----------------------------------------------------
Fax | 678-324-8017
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NP
-----------------------------------------------------
Name | TEMEKA L JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-324-8009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------