Provider Demographics
NPI:1699197582
Name:SACRED HEART MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:SACRED HEART MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANKLIN
Authorized Official - Middle Name:THEODORE
Authorized Official - Last Name:VON HACK-PRESTINARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-530-0877
Mailing Address - Street 1:3146 CHAMBLEE DUNWOODY RD STE 103
Mailing Address - Street 2:
Mailing Address - City:CHAMBLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30341-2967
Mailing Address - Country:US
Mailing Address - Phone:678-530-0877
Mailing Address - Fax:678-530-0700
Practice Address - Street 1:3146 CHAMBLEE DUNWOODY RD STE 103
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-2967
Practice Address - Country:US
Practice Address - Phone:678-530-0877
Practice Address - Fax:678-530-0700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39501261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care