Provider Demographics
NPI:1386921310
Name:LIFE CARE FAMILY PRACTICE
Entity type:Organization
Organization Name:LIFE CARE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-949-9804
Mailing Address - Street 1:8464 ADAIR ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1839
Mailing Address - Country:US
Mailing Address - Phone:770-949-9804
Mailing Address - Fax:770-949-9842
Practice Address - Street 1:8464 ADAIR ST
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1839
Practice Address - Country:US
Practice Address - Phone:770-949-9804
Practice Address - Fax:770-949-9842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-04
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
GA037626305R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF73661Medicare UPIN