Provider Demographics
NPI:1235415696
Name:NORTHLAKE MEDICAL & WELLNESS CENTER
Entity Type:Organization
Organization Name:NORTHLAKE MEDICAL & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMMACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-551-7810
Mailing Address - Street 1:2244 HENDERSON MILL RD NE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2760
Mailing Address - Country:US
Mailing Address - Phone:678-551-7810
Mailing Address - Fax:678-551-7815
Practice Address - Street 1:2244 HENDERSON MILL RD NE
Practice Address - Street 2:SUITE 108
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2760
Practice Address - Country:US
Practice Address - Phone:678-551-7810
Practice Address - Fax:678-551-7815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036281207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1649205642OtherCOMMERCIAL INSURANCE