MEDICARE: PMR GEORGIA HOLDING, LLC

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	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1164194858
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PMR GEORGIA HOLDING, LLC

Provider Business Mailing Address
First Line	:	1395 NW 167TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33169-5710
Country	:	US
Telephone Number	:	305-628-6117
Fax Number	:

Provider Business Practice Location Address
First Line	:	1057 MAIN ST
Second Line	:
City	:	FOREST PARK
State	:	GA
Zip	:	30297-1482
Country	:	US
Telephone Number	:	404-301-4555
Fax Number	:	404-301-4482

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MARY CHEN
Credential	:
Telephone Number	:	305-628-6117

Provider Enumeration Date	:	09/30/2021
Last Update Date	:	09/30/2021

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