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General NPI Number Information
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NPI Number | 1992111280
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Entity Type | Organization
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Legal Business Name | LIFEQUEST KENNESAW, LLC
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Dates
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Enumeration Date | 07/08/2014
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Last Update Date | 09/12/2014
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Provider Practice Location Address
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Address Line | 3362 ACWORTH SUMMIT BLVD NW
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City | ACWORTH
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State | GA
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Zip | 30101-5770
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Country | US
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Telephone | 678-973-0635
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Fax |
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Provider Business Mailing Address
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Address Line | 3362 ACWORTH SUMMIT BLVD NW
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City | ACWORTH
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State | GA
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Zip | 30101-5770
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Country | US
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Telephone | 678-973-0635
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | JAMES BROUSSARD
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Credential |
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Telephone | 678-973-0635
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 33753
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License Number State | GA
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