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General NPI Number Information
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NPI Number | 1780936252
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Entity Type | Organization
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Legal Business Name | 4KLOOR LLC
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Dates
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Enumeration Date | 10/09/2012
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Last Update Date | 10/10/2012
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Provider Practice Location Address
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Address Line | 1558 MARIETTA HWY 230
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City | CANTON
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State | GA
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Zip | 30114-3616
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Country | US
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Telephone | 678-880-6879
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Fax | 678-880-8834
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Provider Business Mailing Address
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Address Line | 1558 MARIETTA HYW 230
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City | CANTON
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State | GA
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Zip | 30114
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Country | US
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Telephone | 678-880-6879
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Fax | 678-880-8834
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT
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Name | CESAR LOOR
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Credential |
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Telephone | 678-880-6879
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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 | 160312
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 00658
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License Number State | GA
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