Provider Demographics
NPI:1104536853
Name:GOODLIFE CARDIAC CARE, LLC
Entity type:Organization
Organization Name:GOODLIFE CARDIAC CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LAQUETA
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:770-383-1415
Mailing Address - Street 1:2400 HERODIAN WAY SE STE 220
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-8500
Mailing Address - Country:US
Mailing Address - Phone:770-383-1415
Mailing Address - Fax:
Practice Address - Street 1:2400 HERODIAN WAY SE STE 220
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-8500
Practice Address - Country:US
Practice Address - Phone:770-383-1415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty