Organization
PROVIDENT HEALTHCARE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. LAKSHMAN K DINAVAHI MD (CHIEF MEDICAL OFFICER)
(678) 390-0120
Entity
Organization
Contact information
Practice address
3505 LASSITER FALLS DR NE, MARIETTA, GA 30062-4199
(414) 916-9031
Mailing address
3063 PEACHTREE INDUSTRIAL BLVD, STE 200, DULUTH, GA 30097-8639
(678) 390-0120
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
07088
GA
207RG0300X
Geriatric Medicine (Internal Medicine) Physician
Primary
07088
GA
207RH0002X
Hospice and Palliative Medicine (Internal Medicine) Physician
07088
GA
Other
Enumeration date
07/21/2015
Last updated
07/22/2015
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