| Organization Name: | EAGLE DRIVE FAMILY MEDICINE PC |
| NPI Number: | 1750514295 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RICHARD LEON MANRIQUE (PRESIDENT) |
| Mailing Address: | 1816 Eagle Dr Suite 200-b Woodstock |
| State: | GA US |
| Postal Code: | 301898272 |
| Phone Number: | 6784455995 |
| Fax Number: | |
| NPI Enumeration Date: | 09/01/2009 |
| NPI Last Update Date: | 01/25/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |