Provider Demographics
NPI:1740313196
Name:HISPANIC MEDICAL MANAGEMENT
Entity type:Organization
Organization Name:HISPANIC MEDICAL MANAGEMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:COTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-613-0070
Mailing Address - Street 1:5127 JIMMY CARTER BLVD
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-1619
Mailing Address - Country:US
Mailing Address - Phone:770-613-0070
Mailing Address - Fax:770-613-0990
Practice Address - Street 1:706 GRAYSON HWY
Practice Address - Street 2:SUITE 213
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-5707
Practice Address - Country:US
Practice Address - Phone:770-339-9111
Practice Address - Fax:770-339-9939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory