Provider Demographics
NPI:1447558010
Name:MOFAZZAL SURAIYA LLC
Entity Type:Organization
Organization Name:MOFAZZAL SURAIYA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIL
Authorized Official - Middle Name:
Authorized Official - Last Name:IMRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-587-8500
Mailing Address - Street 1:2775 CRUSE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-7140
Mailing Address - Country:US
Mailing Address - Phone:404-587-8500
Mailing Address - Fax:770-939-5682
Practice Address - Street 1:1015 OMAHA DR
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-4967
Practice Address - Country:US
Practice Address - Phone:404-587-8500
Practice Address - Fax:770-939-5682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health