=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891410320
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | APOLLO OCCUPATIONAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2022
-----------------------------------------------------
Last Update Date | 10/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 845 S CARROLL RD STE A
-----------------------------------------------------
City | VILLA RICA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30180-7035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-315-2650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12461 VETERANS MEMORIAL HWY STE 402
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-2025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-262-7011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. CAMELIA RUFFIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-262-7011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------