Provider Demographics
NPI:1255600565
Name:CLINICA SANTA MARIA LLC
Entity type:Organization
Organization Name:CLINICA SANTA MARIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-928-8450
Mailing Address - Street 1:6158 HIGHWAY 92 STE 101
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-2332
Mailing Address - Country:US
Mailing Address - Phone:770-928-8450
Mailing Address - Fax:770-928-8452
Practice Address - Street 1:6158 HIGHWAY 92 STE 101
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102-2332
Practice Address - Country:US
Practice Address - Phone:770-928-8450
Practice Address - Fax:770-928-8452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-16
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALC20110001409261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service