# EAGLE DRIVE FAMILY MEDICINE PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1750514295
- **Authorized official:** RICHARD LEON MANRIQUE M.D. (PRESIDENT)
- **Authorized official phone:** (678) 445-5995

## Contact information

- **Practice address:** 1816 EAGLE DR, SUITE 200-B, WOODSTOCK, GA 30189-8272
- **Practice address phone:** (678) 445-5995
- **Mailing address:** 1816 EAGLE DR, SUITE 200-B, WOODSTOCK, GA 30189-8272
- **Mailing address phone:** (678) 445-5995

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | — | — | Yes |

## Other

- **Enumeration date:** 09/01/2009
- **Last updated:** 01/25/2012