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NPI Code Detail

MEDICARE: PROVIDENCE NEUROPSYCHIATRIC HEALTH, LLC

MEDICARE: PROVIDENCE NEUROPSYCHIATRIC HEALTH, 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
12084P0800XPsychiatry Physician

General Provider Information

NPI Number : 1710483409
Entity Type Code : Organization
Provider Name (Legal Business Name) : PROVIDENCE NEUROPSYCHIATRIC HEALTH, LLC
Provider Business Mailing Address
First Line : 2483 HERITAGE VILLAGE
Second Line : SUITE 16 - 490
City : SNELLVILLE
State : GA
Zip : 30078
Country : US
Telephone Number : 470-610-0644
Fax Number : 470-610-0650
Provider Business Practice Location Address
First Line : 709 BREEDLOVE DR
Second Line :
City : MONROE
State : GA
Zip : 30655-2055
Country : US
Telephone Number : 717-460-8885
Fax Number :
Authorized Official
Title or Position : OWNER
Name : DR. ADEWUMI ADEBOMOJO
Credential : MD
Telephone Number : 717-460-8885
Provider Enumeration Date : 04/02/2018
Last Update Date : 10/30/2022

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