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General NPI Number Information
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NPI Number | 1922339837
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Entity Type | Organization
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Legal Business Name | BOELLA ENTERPRISES,LLC
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Dates
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Enumeration Date | 01/18/2010
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Last Update Date | 07/20/2011
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Provider Practice Location Address
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Address Line | 811 KENNESAW AVE NW
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City | MARIETTA
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State | GA
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Zip | 30060-1002
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Country | US
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Telephone | 770-422-2451
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Fax | 770-499-2235
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Provider Business Mailing Address
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Address Line | 4277 STEF LN NW
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City | KENNESAW
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State | GA
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Zip | 30152-7700
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Country | US
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Telephone | 770-419-1799
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. TRINA RENEE CAIN
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Credential | APRN,BC
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Telephone | 770-419-1799
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN054027NP
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License Number State | GA
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