Provider Demographics
NPI:1699912113
Name:RELIANCE FAMILY CARE
Entity type:Organization
Organization Name:RELIANCE FAMILY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NIMISHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:TRIVEDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-610-6649
Mailing Address - Street 1:PO BOX 1100
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-8651
Mailing Address - Country:US
Mailing Address - Phone:678-610-6649
Mailing Address - Fax:678-610-6025
Practice Address - Street 1:345 HUNTINGTON PLACE CT
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8651
Practice Address - Country:US
Practice Address - Phone:678-272-7280
Practice Address - Fax:678-610-6025
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOCUST GROVE FAMILY MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-21
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053715207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA117518856BMedicaid
GAI01657Medicare UPIN