Provider Demographics
NPI:1356616338
Name:ELEVEN 11 MEDICAL MANAGEMENT, LLC
Entity type:Organization
Organization Name:ELEVEN 11 MEDICAL MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-235-2401
Mailing Address - Street 1:438 HENRY FORD II AVE
Mailing Address - Street 2:
Mailing Address - City:HAPEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30354-1622
Mailing Address - Country:US
Mailing Address - Phone:678-235-2401
Mailing Address - Fax:678-235-2403
Practice Address - Street 1:438 HENRY FORD II AVE
Practice Address - Street 2:
Practice Address - City:HAPEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30354-1622
Practice Address - Country:US
Practice Address - Phone:678-235-2401
Practice Address - Fax:678-235-2403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty