Provider Demographics
NPI:1639571532
Name:SOUTH ATLANTA MUA CENTER, LLC
Entity Type:Organization
Organization Name:SOUTH ATLANTA MUA CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:855-880-7568
Mailing Address - Street 1:P.O. BOX 1601
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867
Mailing Address - Country:US
Mailing Address - Phone:855-880-7568
Mailing Address - Fax:866-837-9033
Practice Address - Street 1:541 FOREST PKWY
Practice Address - Street 2:STE 14
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-6144
Practice Address - Country:US
Practice Address - Phone:855-880-7568
Practice Address - Fax:866-837-9033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-23
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031143261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical