Provider Demographics
NPI:1922273747
Name:SOUTHERN HEALTHCARE PROVIDER GROUP, LLC
Entity Type:Organization
Organization Name:SOUTHERN HEALTHCARE PROVIDER GROUP, LLC
Other - Org Name:SOUTHERN HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDRANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-792-7893
Mailing Address - Street 1:PO BOX 6881
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30065-0881
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2754 N DECATUR RD
Practice Address - Street 2:SUITE 110
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5917
Practice Address - Country:US
Practice Address - Phone:404-838-0082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO07897111NR0400X
GA021447208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty