Provider Demographics
NPI:1184085821
Name:BUCKHEAD BREAST CARE, LLC
Entity type:Organization
Organization Name:BUCKHEAD BREAST CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-695-0772
Mailing Address - Street 1:1015 NOTTINGHAM LN NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-6002
Mailing Address - Country:US
Mailing Address - Phone:404-695-0772
Mailing Address - Fax:
Practice Address - Street 1:35 COLLIER RD NW
Practice Address - Street 2:SUITE 185
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1613
Practice Address - Country:US
Practice Address - Phone:404-603-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044956208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty