Provider Demographics
NPI:1609559434
Name:PCCB MEDICAL, LLC
Entity Type:Organization
Organization Name:PCCB MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PINKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:BHUTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-672-1065
Mailing Address - Street 1:1860 CHAMDUN PL
Mailing Address - Street 2:
Mailing Address - City:CHAMBLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1767
Mailing Address - Country:US
Mailing Address - Phone:135-267-2106
Mailing Address - Fax:
Practice Address - Street 1:1860 CHAMDUN PL
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-1767
Practice Address - Country:US
Practice Address - Phone:135-267-2106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-09
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility