Organization Name: | SURGICARE GWINNETT |
NPI Number: | 1164833398 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | CHRISTOPHER IBIKUNLE (ADMINISTRATOR) |
Mailing Address: | 367 Athens Hwy Bld 100 Suite B Loganville |
State: | GA US |
Postal Code: | 300522204 |
Phone Number: | 6784666760 |
Fax Number: | |
NPI Enumeration Date: | 05/09/2014 |
NPI Last Update Date: | 05/20/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QA1903X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Ambulatory Surgical |
Taxonomy Definition: |