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General NPI Number Information
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NPI Number | 1871594499
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Entity Type | Organization
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Legal Business Name | NORTHLAKE ENDOSCOPY CENTER
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Dates
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Enumeration Date | 08/04/2005
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Last Update Date | 05/08/2008
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Provider Practice Location Address
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Address Line | 1459 MONTREAL RD SU 204
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City | TUCKER
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State | GA
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Zip | 30084-6900
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Country | US
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Telephone | 770-939-4721
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Fax | 770-939-1187
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Provider Business Mailing Address
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Address Line | 1459 MONTREAL RD SU 204
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City | TUCKER
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State | GA
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Zip | 30084-6900
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Country | US
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Telephone | 770-939-4721
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Fax | 770-939-1187
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RALPH ROBERT BETON
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Credential | MD
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Telephone | 770-939-4721
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 044047
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License Number State | GA
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