MEDICARE: EBT HOLDINGS OF GEORGIA INCORPORATED

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1871287250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EBT HOLDINGS OF GEORGIA INCORPORATED

Provider Business Mailing Address
First Line	:	1430 FIVE FORKS TRICKUM RD STE 220
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30044-8183
Country	:	US
Telephone Number	:	786-352-7021
Fax Number	:	786-698-1632

Provider Business Practice Location Address
First Line	:	1430 FIVE FORKS TRICKUM RD STE 220
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30044-8183
Country	:	US
Telephone Number	:	786-352-7021
Fax Number	:	786-698-1632

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	ENRIQUE MASSUET VALDES
Credential	:
Telephone Number	:	786-352-7021

Provider Enumeration Date	:	06/07/2023
Last Update Date	:	12/05/2023

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