MEDICARE: COLLECTIVE CONSULTING ENTERPRISE

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	363AS0400X	Surgical Physician Assistant	004091	GA

General Provider Information

NPI Number	:	1194984690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLECTIVE CONSULTING ENTERPRISE

Provider Business Mailing Address
First Line	:	6555 SUGARLOAF PKWY
Second Line	:	SUITE 307,#231
City	:	DULUTH
State	:	GA
Zip	:	30097
Country	:	US
Telephone Number	:	678-379-4557
Fax Number	:	678-475-3992

Provider Business Practice Location Address
First Line	:	6555 SUGARLOAF PKWY
Second Line	:	SUITE 307,#231
City	:	DULUTH
State	:	GA
Zip	:	30097-4930
Country	:	US
Telephone Number	:	678-379-4557
Fax Number	:	678-475-3992

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	MRS. ABIMBOLA ABOSEDE OKUNSANYA
Credential	:
Telephone Number	:	678-379-4557

Provider Enumeration Date	:	06/09/2008
Last Update Date	:	06/09/2008

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