Provider Demographics
NPI:1831378249
Name:LAWRENCEVILLE FAMILY PRACTICE
Entity type:Organization
Organization Name:LAWRENCEVILLE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GUERRESO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:770-338-0089
Mailing Address - Street 1:1730 LAWRENCEVILLE SUWANEE RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-3507
Mailing Address - Country:US
Mailing Address - Phone:770-338-0089
Mailing Address - Fax:770-338-0091
Practice Address - Street 1:1730 LAWRENCEVILLE SUWANEE RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-3507
Practice Address - Country:US
Practice Address - Phone:770-338-0089
Practice Address - Fax:770-338-0091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038787302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3463Medicare PIN