Provider Demographics
NPI:1710236880
Name:ELITE FAMILY PRACTICE
Entity Type:Organization
Organization Name:ELITE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DELANIA
Authorized Official - Middle Name:W
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-715-2993
Mailing Address - Street 1:6126 PRESTLEY MILL RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-5623
Mailing Address - Country:US
Mailing Address - Phone:678-715-2993
Mailing Address - Fax:678-715-2827
Practice Address - Street 1:6126 PRESTLEY MILL RD
Practice Address - Street 2:SUITE H
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5623
Practice Address - Country:US
Practice Address - Phone:678-715-2993
Practice Address - Fax:678-715-2827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041745305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization