Provider Demographics
NPI:1558665653
Name:GODEL FIRST MEDICAL CLINICS INC.
Entity Type:Organization
Organization Name:GODEL FIRST MEDICAL CLINICS INC.
Other - Org Name:GODEL FIRST MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:IFEANYICHUKWU
Authorized Official - Last Name:EFOBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-879-7707
Mailing Address - Street 1:1525 E PARK PLACE BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3453
Mailing Address - Country:US
Mailing Address - Phone:770-879-7707
Mailing Address - Fax:770-879-7708
Practice Address - Street 1:1525 E PARK PLACE BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3453
Practice Address - Country:US
Practice Address - Phone:770-879-7707
Practice Address - Fax:770-879-7708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA594981959AMedicaid