Basic Information
Provider Information
NPI: 1306965611
EntityType: 2
ReplacementNPI:  
OrganizationName: MINUTECLINIC DIAGNOSTIC OF GEORGIA LLC
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Mailing Information
Address1: PO BOX 772
Address2: MINUTECLINIC CREDENTIALING-MC2295
City: WOONSOCKET
State: RI
PostalCode: 028950784
CountryCode: US
TelephoneNumber: 8663892727
FaxNumber: 4014063539
Practice Location
Address1: 3905 DUE WEST RD NW
Address2:  
City: MARIETTA
State: GA
PostalCode: 300641019
CountryCode: US
TelephoneNumber: 8663892727
FaxNumber: 4014063539
Other Information
ProviderEnumerationDate: 03/28/2007
LastUpdateDate: 03/26/2020
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AuthorizedOfficialLastName: PINCINCE
AuthorizedOfficialFirstName: DEBORAH
AuthorizedOfficialMiddleName: JEAN
AuthorizedOfficialTitleorPosition: ADMINISTRATOR
AuthorizedOfficialTelephone: 4017703813
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: MINUTECLINIC, LLC
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NPICertificationDate: 03/26/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X  Y193400000X MULTIPLE SINGLE SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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