Organization
EXECUTIVE MEDICAL HEALTHCARE SERVICES
Active
Other names
Wellness Medicine
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JELUNDER CLARK M.D. (MEDICAL DIRECTOR, FAMILY PRACTICE)
(678) 479-1234
Entity
Organization
Contact information
Practice address
990 BEAR CREEK BLVD, SUITE G, HAMPTON, GA 30228-1864
(678) 479-1234
(678) 479-5678
Mailing address
PO BOX 224, LOVEJOY, GA 30250-0224
(678) 479-1234
(678) 479-5678
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
042544
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
042544
MEDICAL LICENSE
GA
01
—
11D1014694
CLIA
GA
05
—
250161583A
—
GA
Enumeration date
04/02/2007
Last updated
03/07/2023
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