Provider Demographics
NPI:1770995946
Name:STONE MOUNTAIN SKIN HEALTH CENTER
Entity type:Organization
Organization Name:STONE MOUNTAIN SKIN HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NGUENGUE-SOWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-293-4163
Mailing Address - Street 1:5430 JIMMY CARTER BLVD
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093
Mailing Address - Country:US
Mailing Address - Phone:770-508-8241
Mailing Address - Fax:770-558-1324
Practice Address - Street 1:5430 JIMMY CARTER BLVD
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093
Practice Address - Country:US
Practice Address - Phone:770-508-8241
Practice Address - Fax:770-558-1324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-22
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59834261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA142943194AMedicaid