| NPI | 1629169164 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | NIMISHA J TRIVEDI Owner 678-610-6649 |
| Organization Subpart ? | No |
| Primary Taxonomy | 332900000X Non-Pharmacy Dispensing Site (Licence: GA 053715) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 053715) |
| Enumeration Date | 2006-09-28 |
| Last Update Date | 2016-03-14 |