Provider Demographics
NPI:1669716718
Name:PROFESSIONAL MEDICAL & REHAB CLINIC
Entity type:Organization
Organization Name:PROFESSIONAL MEDICAL & REHAB CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-748-4952
Mailing Address - Street 1:2636 MARTIN LUTHER KING JR DR SW
Mailing Address - Street 2:STE. 12
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-1634
Mailing Address - Country:US
Mailing Address - Phone:404-748-4952
Mailing Address - Fax:404-696-2823
Practice Address - Street 1:2636 MARTIN LUTHER KING JR DR SW
Practice Address - Street 2:STE. 12
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-1634
Practice Address - Country:US
Practice Address - Phone:404-748-4952
Practice Address - Fax:404-696-2823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care