Provider Demographics
NPI:1255661302
Name:BUCKHEAD EXPRESS CLINIC PC
Entity type:Organization
Organization Name:BUCKHEAD EXPRESS CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AGODI
Authorized Official - Middle Name:U
Authorized Official - Last Name:NWOSU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-483-1493
Mailing Address - Street 1:3613A RAEFORD RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-2113
Mailing Address - Country:US
Mailing Address - Phone:910-483-1493
Mailing Address - Fax:910-920-4212
Practice Address - Street 1:3613A RAEFORD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-2113
Practice Address - Country:US
Practice Address - Phone:910-483-1493
Practice Address - Fax:910-920-4212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty