Provider Demographics
NPI:1336762913
Name:FAVOR FAMILY MEDICAL PRACTICE LLC
Entity Type:Organization
Organization Name:FAVOR FAMILY MEDICAL PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EUNICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOMEH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:678-880-8893
Mailing Address - Street 1:103 MOUNTAIN BROOK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-9078
Mailing Address - Country:US
Mailing Address - Phone:678-880-8893
Mailing Address - Fax:
Practice Address - Street 1:103 MOUNTAIN BROOK DR STE 100
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-9078
Practice Address - Country:US
Practice Address - Phone:678-880-8893
Practice Address - Fax:678-880-8589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-18
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA13911414Medicaid