=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932683083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUICK CARE DIAGNOSTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2018
-----------------------------------------------------
Last Update Date | 09/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4760 AUSTELL RD STE 7
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106-2007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-366-9614
-----------------------------------------------------
Fax | 877-779-5837
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4760 AUSTELL RD STE 7
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106-2007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-366-9614
-----------------------------------------------------
Fax | 877-779-5837
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. OLUWOLE OLUWOLE
-----------------------------------------------------
Credential | MD,
-----------------------------------------------------
Telephone | 770-366-9614
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------