Provider Demographics
NPI:1194128447
Name:PROCARE MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:PROCARE MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-428-8700
Mailing Address - Street 1:1395 S MARIETTA PKWY SE
Mailing Address - Street 2:BLDG 100 SUITE 102
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-4440
Mailing Address - Country:US
Mailing Address - Phone:770-425-8700
Mailing Address - Fax:770-425-8740
Practice Address - Street 1:1395 S MARIETTA PKWY SE
Practice Address - Street 2:BLDG 100 SUITE 102
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-4440
Practice Address - Country:US
Practice Address - Phone:770-425-8700
Practice Address - Fax:770-425-8740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty