Provider Demographics
NPI:1518096122
Name:DOMINION ORTHOPAEDIC CLINIC, LLC
Entity Type:Organization
Organization Name:DOMINION ORTHOPAEDIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-455-4009
Mailing Address - Street 1:5555 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1703
Mailing Address - Country:US
Mailing Address - Phone:770-455-4009
Mailing Address - Fax:770-455-4065
Practice Address - Street 1:6 CONCOURSE PKWY STE 260
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-6117
Practice Address - Country:US
Practice Address - Phone:770-455-4009
Practice Address - Fax:770-455-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037539174400000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID