Provider Demographics
NPI:1891234159
Name:NEW LIFE PROGRESSIVE HEALTH
Entity Type:Organization
Organization Name:NEW LIFE PROGRESSIVE HEALTH
Other - Org Name:NEW LIFE WELLNESS WITH RABIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RABIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAUGHNS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:706-688-9355
Mailing Address - Street 1:3472 OLD THOMPSON MILL RD
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-5403
Mailing Address - Country:US
Mailing Address - Phone:404-234-4653
Mailing Address - Fax:
Practice Address - Street 1:3515 BRASELTON HWY
Practice Address - Street 2:SUITE E-2
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-5926
Practice Address - Country:US
Practice Address - Phone:706-688-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5609363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty