Provider Demographics
NPI:1154080786
Name:ASTHMA ALLERGY AND IMMUNOLOGY CLINIC LLC
Entity Type:Organization
Organization Name:ASTHMA ALLERGY AND IMMUNOLOGY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOSAMANE
Authorized Official - Middle Name:S
Authorized Official - Last Name:PRABHAKARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-489-7901
Mailing Address - Street 1:756 PENINSULA OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-6062
Mailing Address - Country:US
Mailing Address - Phone:678-489-7901
Mailing Address - Fax:
Practice Address - Street 1:147 N PARK TRL
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7373
Practice Address - Country:US
Practice Address - Phone:678-489-7901
Practice Address - Fax:833-559-0864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-10
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty