Provider Demographics
NPI:1225041247
Name:WEST END MEDICAL CENTERS, THE FAMILY HEALTH CENTER @ BOLTON VILLAGE
Entity Type:Organization
Organization Name:WEST END MEDICAL CENTERS, THE FAMILY HEALTH CENTER @ BOLTON VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERTAING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-752-1400
Mailing Address - Street 1:868 YORK AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-2750
Mailing Address - Country:US
Mailing Address - Phone:404-752-1400
Mailing Address - Fax:404-756-8749
Practice Address - Street 1:2011 BOLTON RD NW
Practice Address - Street 2:SUITE 104
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-1137
Practice Address - Country:US
Practice Address - Phone:404-752-1400
Practice Address - Fax:404-756-8749
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST END MEDICAL CENTERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-14
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANON PROFIT EXEMPT261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000437478DMedicaid
GA000437478DMedicaid