Provider Demographics
NPI:1972036978
Name:WATERWORKSNOW, INCORPORATED
Entity Type:Organization
Organization Name:WATERWORKSNOW, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:6785-588-6767
Mailing Address - Street 1:PO BOX 370354
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30037-0354
Mailing Address - Country:US
Mailing Address - Phone:678-558-6767
Mailing Address - Fax:
Practice Address - Street 1:1525 E PARK PLACE BLVD
Practice Address - Street 2:SUITE 1800
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3453
Practice Address - Country:US
Practice Address - Phone:678-558-6767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA48419261QH0100X, 261QM2500X, 261QP2000X, 261QR1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch