Provider Demographics
NPI:1053511493
Name:NORTHWEST GEORGIA MEDICAL CLINIC 2LLC
Entity Type:Organization
Organization Name:NORTHWEST GEORGIA MEDICAL CLINIC 2LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:ACCOUNTING
Authorized Official - Phone:404-943-0205
Mailing Address - Street 1:PO BOX 468329
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31146-8329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1105 N 5TH AVE NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2603
Practice Address - Country:US
Practice Address - Phone:404-943-0205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center