=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982160735
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASA MED LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2019
-----------------------------------------------------
Last Update Date | 02/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2295 RONALD REAGAN PKWY
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30078-5698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-982-2332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3292 THOMPSON BRIDGE RD STE 371
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30506-1561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-982-2332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHEETAL MANGALAT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-982-2332
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------