=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992026330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERIMETER HEALTH AND WELLNESS CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2010
-----------------------------------------------------
Last Update Date | 06/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1838 OLD NORCROSS RD STE 200
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-8804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-236-8686
-----------------------------------------------------
Fax | 770-236-8687
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1838 OLD NORCROSS RD STE 200
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-8804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-236-8686
-----------------------------------------------------
Fax | 770-236-8687
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VICTORIA SANCHEZ
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 770-236-8686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 084728
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------