Provider Demographics
NPI:1609194620
Name:ATLANTA LIFESTYLE MEDICAL CENTER
Entity Type:Organization
Organization Name:ATLANTA LIFESTYLE MEDICAL CENTER
Other - Org Name:ATLANTA LIFESTYLE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ROOKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-769-3928
Mailing Address - Street 1:6090 INDIAN WOOD CIR SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2969
Mailing Address - Country:US
Mailing Address - Phone:404-691-4549
Mailing Address - Fax:
Practice Address - Street 1:131 PONCE DE LEON AVE NE
Practice Address - Street 2:SUITE 230
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1962
Practice Address - Country:US
Practice Address - Phone:404-769-3928
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-14
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0338012083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty