MEDICARE: DANSFORTH, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	047279	GA

General Provider Information

NPI Number	:	1124383146
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DANSFORTH, INC

Provider Business Mailing Address
First Line	:	PO BOX 56
Second Line	:
City	:	SUWANEE
State	:	GA
Zip	:	30024-0056
Country	:	US
Telephone Number	:	770-856-8736
Fax Number	:

Provider Business Practice Location Address
First Line	:	245 PEACHTREE INDUSTRIAL BLVD
Second Line	:	SUITE100
City	:	SUGAR HILL
State	:	GA
Zip	:	30518-9126
Country	:	US
Telephone Number	:	770-856-8736
Fax Number	:

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	DR. DAWN R WILSON
Credential	:	M.D.
Telephone Number	:	770-856-8736

Provider Enumeration Date	:	07/05/2012
Last Update Date	:	07/05/2012

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