Provider Demographics
NPI:1205334620
Name:GEORGIA PRENATAL LLC
Entity type:Organization
Organization Name:GEORGIA PRENATAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL CONSULTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALENCIA
Authorized Official - Middle Name:W
Authorized Official - Last Name:FLOURNOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-579-2188
Mailing Address - Street 1:950 INDIAN TRAIL LILBURN RD NW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-1721
Mailing Address - Country:US
Mailing Address - Phone:470-545-2131
Mailing Address - Fax:770-809-5154
Practice Address - Street 1:950 INDIAN TRAIL LILBURN RD NW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-1721
Practice Address - Country:US
Practice Address - Phone:470-545-2131
Practice Address - Fax:770-809-5154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-31
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA58124261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID