Provider Demographics
NPI:1720598030
Name:PRODIAGNOSTICS MEDICAL CENTER
Entity Type:Organization
Organization Name:PRODIAGNOSTICS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTICIONER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:ESCOBAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-880-4517
Mailing Address - Street 1:6460 HIGHWAY 92 STE 200
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-2998
Mailing Address - Country:US
Mailing Address - Phone:678-915-1891
Mailing Address - Fax:
Practice Address - Street 1:6460 HIGHWAY 92 STE 200
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102-2998
Practice Address - Country:US
Practice Address - Phone:678-915-1891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN225443363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty