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General NPI Number Information
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NPI Number | 1992826705
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Entity Type | Organization
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Legal Business Name | EXECUTIVE MEDICAL HEALTHCARE SERVICES
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Dates
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Enumeration Date | 04/02/2007
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 990 BEAR CREEK BLVD SUITE G
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City | HAMPTON
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State | GA
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Zip | 30228-1864
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Country | US
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Telephone | 678-479-1234
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Fax | 678-479-5678
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Provider Business Mailing Address
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Address Line | PO BOX 224
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City | LOVEJOY
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State | GA
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Zip | 30250-0224
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Country | US
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Telephone | 678-479-1234
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Fax | 678-479-5678
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Authorized Official
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Title or Position | MEDICAL DIRECTOR, FAMILY PRACTICE
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Name | DR. JELUNDER CLARK
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Credential | M.D.
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Telephone | 678-479-1234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 042544
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License Number State | GA
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