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General NPI Number Information
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NPI Number | 1881419406
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Entity Type | Organization
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Legal Business Name | DIVINE MERCY MEDICAL GROUP LLC
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Dates
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Enumeration Date | 11/19/2024
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Last Update Date | 11/19/2024
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Provider Practice Location Address
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Address Line | 1260 HIRAM DAVIS RD
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City | LAWRENCEVILLE
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State | GA
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Zip | 30045-6628
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Country | US
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Telephone | 877-258-6331
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Fax | 718-362-1651
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Provider Business Mailing Address
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Address Line | 1260 HIRAM DAVIS RD
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City | LAWRENCEVILLE
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State | GA
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Zip | 30045-6628
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Country | US
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Telephone | 877-258-6331
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ISABELLE VIKUMITSI
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Credential | NP
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Telephone | 678-992-6132
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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