Provider Demographics
NPI:1073881405
Name:HAMILTON MILL FAMILY COMPLETE CARE, LLC
Entity Type:Organization
Organization Name:HAMILTON MILL FAMILY COMPLETE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-614-6630
Mailing Address - Street 1:3509 BRASELTON HWY
Mailing Address - Street 2:BUILDING F
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1107
Mailing Address - Country:US
Mailing Address - Phone:770-614-6630
Mailing Address - Fax:770-614-6684
Practice Address - Street 1:3509 BRASELTON HWY
Practice Address - Street 2:BUILDING F
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1107
Practice Address - Country:US
Practice Address - Phone:770-614-6630
Practice Address - Fax:770-614-6684
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT MEDICAL CENTER, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA07581111N00000X
207R00000X
GA176596363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty