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373 W Lake Ave Nw Atlanta GA 30318-8123 | |
| (770) 366-9614 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Family Medicine |
| Location | 373 W Lake Ave Nw, Atlanta, Georgia |
| Authorized Official Name and Position | Emman Desir (CEO) |
| Authorized Official Contact | 9544877464 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
4760 Austell Rd Ste 7 Austell GA 30106-2007 Ph: () - | 373 W Lake Ave Nw Atlanta GA 30318-8123 Ph: (770) 366-9614 |
| NPI Number | 1649739020 |
|---|---|
| Provider Enumeration Date | 03/15/2019 |
| Last Update Date | 08/21/2019 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1649739020 | NPI | - | NPPES |
| 003142287S | Medicaid | GA | |
| 69322 | Other | GA | LICENSE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
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