Provider Demographics
NPI:1518011790
Name:IDEAL MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:IDEAL MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-812-2625
Mailing Address - Street 1:3039 PREMIERE PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-4905
Mailing Address - Country:US
Mailing Address - Phone:678-812-2625
Mailing Address - Fax:
Practice Address - Street 1:3523 BUFORD HWY NE
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-1201
Practice Address - Country:US
Practice Address - Phone:678-812-2625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty