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General NPI Number Information
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NPI Number | 1780852921
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Entity Type | Organization
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Legal Business Name | CHILDREN'S CLINIC OF ATLANTA
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Dates
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Enumeration Date | 02/11/2008
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Last Update Date | 02/11/2008
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Provider Practice Location Address
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Address Line | 2967 A GRANDVIEW AVE NE
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City | ATLANTA
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State | GA
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Zip | 30305
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Country | US
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Telephone | 404-814-0733
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Fax | 404-814-0584
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Provider Business Mailing Address
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Address Line | PO BOX 11989
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City | ATLANTA
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State | GA
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Zip | 30355-1989
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Country | US
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Telephone | 404-814-0733
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Fax | 404-814-0584
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Authorized Official
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Title or Position | OWNER
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Name | DR. NINA BRAZELL BASS
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Credential | M.D.
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Telephone | 404-814-0733
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 031559
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License Number State | GA
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