MEDICARE: TWO DRAGONS TAI CHI 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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1760095202
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWO DRAGONS TAI CHI LLC

Provider Business Mailing Address
First Line	:	4373 MARJORIE RD
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30039-6538
Country	:	US
Telephone Number	:	404-624-6151
Fax Number	:	770-860-1815

Provider Business Practice Location Address
First Line	:	4373 MARJORIE RD
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30039-6538
Country	:	US
Telephone Number	:	404-624-6151
Fax Number	:	770-860-1815

Authorized Official
Title or Position	:	CO-OWNER
Name	:	MR. GENE DOUGLAS MCFADDEN JR.
Credential	:
Telephone Number	:	404-624-6151

Provider Enumeration Date	:	08/25/2020
Last Update Date	:	08/25/2020

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