Organization
PROVIDENCE HEALTHCARE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. MARY LEACH (OFFICE MANAGER)
(770) 676-6000
Entity
Organization
Contact information
Practice address
4646 N SHALLOWFORD RD, ATLANTA, GA 30338-6304
(770) 676-6000
(770) 392-9805
Mailing address
4646 N SHALLOWFORD RD, ATLANTA, GA 30338-6304
(770) 676-6000
(770) 392-9805
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
CHIR005530
GA
171100000X
Acupuncturist
000186
FL
207KI0005X
Clinical & Laboratory Immunology (Allergy & Immunology) Physician
Primary
—
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
50014615
TAT
GA
01
—
826713
BLUECROSS BLUE SHIELD
GA
01
—
D44849
UPIN
GA
Enumeration date
03/30/2007
Last updated
07/21/2022
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