Provider Demographics
NPI:1942477989
Name:MOLD CLINICS OF AMERICA
Entity Type:Organization
Organization Name:MOLD CLINICS OF AMERICA
Other - Org Name:MOLDTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUTCHINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-840-7121
Mailing Address - Street 1:6063 PEACHTREE PKWY
Mailing Address - Street 2:SUITE 203 B
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-3303
Mailing Address - Country:US
Mailing Address - Phone:770-840-7121
Mailing Address - Fax:770-209-9302
Practice Address - Street 1:6063 PEACHTREE PKWY
Practice Address - Street 2:SUITE 203 B
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-3303
Practice Address - Country:US
Practice Address - Phone:770-840-7121
Practice Address - Fax:770-209-9302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMD123445207RI0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory ImmunologyGroup - Single Specialty