Organization
NORTHWEST ENT SURGERY CENTER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CARLOS M EGEA (ADMINISTRATOR)
(770) 427-0368
Entity
Organization
Contact information
Practice address
960 WOODSTOCK PKWY, SUITE 101, WOODSTOCK, GA 30188-4866
(678) 483-8833
(678) 483-8809
Mailing address
960 WOODSTOCK PKWY, SUITE 101, WOODSTOCK, GA 30188-4866
(678) 483-8833
(678) 483-8809
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
028-461
GEORGIA STATE LICENSE
GA
Enumeration date
03/01/2012
Last updated
01/18/2013
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