Provider Demographics
NPI:1811250244
Name:CANDID MEDICAL GROUP LLC
Entity type:Organization
Organization Name:CANDID MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:PRESTON
Authorized Official - Last Name:CAUDILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-718-9969
Mailing Address - Street 1:6525 PROFESSIONAL PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2519
Mailing Address - Country:US
Mailing Address - Phone:770-994-1250
Mailing Address - Fax:770-994-1295
Practice Address - Street 1:6525 PROFESSIONAL PL
Practice Address - Street 2:SUITE C
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2519
Practice Address - Country:US
Practice Address - Phone:770-994-1250
Practice Address - Fax:770-994-1295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain