1972056380 NPI number — ROMULUS PRIMARY CARE SERVICES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972056380 NPI number — ROMULUS PRIMARY CARE SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROMULUS PRIMARY CARE SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972056380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
675 CHESTATEE CREEK DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ACWORTH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30101-3598
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-977-6919
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4439 AUSTELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30106-1839
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-675-7407
Provider Business Practice Location Address Fax Number:
770-693-5922
Provider Enumeration Date:
08/02/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WATTS
Authorized Official First Name:
SHAWNTREL
Authorized Official Middle Name:
MONIQUE
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
770-679-5812

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003145276C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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