Provider Demographics
NPI:1427664333
Name:NATIONS MEDICAL CLINIC INC
Entity type:Organization
Organization Name:NATIONS MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUNOBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-674-9147
Mailing Address - Street 1:3099 BREDKINRIDGE BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1011
Mailing Address - Country:US
Mailing Address - Phone:678-242-8035
Mailing Address - Fax:678-373-1645
Practice Address - Street 1:3099 BREDKINRIDGE BLVD. SUITE 110
Practice Address - Street 2:SUITE 110
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1011
Practice Address - Country:US
Practice Address - Phone:678-242-8035
Practice Address - Fax:678-373-1645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA38161OtherLICENSE
GABA4297215OtherDEA