Provider Demographics
NPI:1639319502
Name:NEW SNELLVILLE CLINIC
Entity Type:Organization
Organization Name:NEW SNELLVILLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:COUILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:BSEE
Authorized Official - Phone:770-736-1735
Mailing Address - Street 1:2331 HENRY CLOWER BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3155
Mailing Address - Country:US
Mailing Address - Phone:770-736-1735
Mailing Address - Fax:770-736-1228
Practice Address - Street 1:2331 HENRY CLOWER BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3155
Practice Address - Country:US
Practice Address - Phone:770-736-1735
Practice Address - Fax:770-736-1228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043268207R00000X, 207RG0300X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty