Provider Demographics
NPI:1073687331
Name:EGLESTON AFFLIATED SERVICES
Entity Type:Organization
Organization Name:EGLESTON AFFLIATED SERVICES
Other - Org Name:CHILDREN'S HEALTHCARE OF ATLANTA AT MOUNT ZION
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER, PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:LOUETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:CODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-785-7876
Mailing Address - Street 1:1584 TULLIE CIR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2311
Mailing Address - Country:US
Mailing Address - Phone:404-785-7928
Mailing Address - Fax:
Practice Address - Street 1:2660 SATELLITE BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5803
Practice Address - Country:US
Practice Address - Phone:404-785-8330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044-079261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care