Provider Demographics
NPI:1750721221
Name:INTERNATIONAL COMMUNITY MEDICAL NETWORK, LLC
Entity type:Organization
Organization Name:INTERNATIONAL COMMUNITY MEDICAL NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KWAME
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-455-3934
Mailing Address - Street 1:1900 WINDSOR DR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-4414
Mailing Address - Country:US
Mailing Address - Phone:559-455-3934
Mailing Address - Fax:
Practice Address - Street 1:1900 WINDSOR DR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-4414
Practice Address - Country:US
Practice Address - Phone:559-455-3934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty