Provider Demographics
NPI:1043495427
Name:ADVANCED MEDICAL CLINICS, P.C.
Entity type:Organization
Organization Name:ADVANCED MEDICAL CLINICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-363-6460
Mailing Address - Street 1:5499 JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30260-3553
Mailing Address - Country:US
Mailing Address - Phone:404-363-6460
Mailing Address - Fax:404-363-4348
Practice Address - Street 1:5499 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:GA
Practice Address - Zip Code:30260-3553
Practice Address - Country:US
Practice Address - Phone:404-363-6460
Practice Address - Fax:404-363-4348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR002353111N00000X
GA047279208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP 3060Medicare PIN