Provider Demographics
NPI:1871759233
Name:JEANNIE-IN-A-BOTTLE LLC
Entity type:Organization
Organization Name:JEANNIE-IN-A-BOTTLE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-849-3443
Mailing Address - Street 1:1343 CANTON RD STE C
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6079
Mailing Address - Country:US
Mailing Address - Phone:866-214-8600
Mailing Address - Fax:678-888-0390
Practice Address - Street 1:3620 HOWELL FERRY RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-3178
Practice Address - Country:US
Practice Address - Phone:678-312-6800
Practice Address - Fax:678-312-5622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041517208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty