Provider Demographics
NPI:1457737926
Name:MC JO LLC
Entity Type:Organization
Organization Name:MC JO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OBINNA
Authorized Official - Middle Name:OKECHUKWU
Authorized Official - Last Name:OLOWU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-836-9799
Mailing Address - Street 1:4505 RIVER STONE TRL
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-8678
Mailing Address - Country:US
Mailing Address - Phone:678-836-9799
Mailing Address - Fax:
Practice Address - Street 1:4505 RIVER STONE TRL
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-8678
Practice Address - Country:US
Practice Address - Phone:678-836-9799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048-R-1373302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization