Provider Demographics
NPI:1962703082
Name:MOFAZZAL SURAIYA LLC
Entity type:Organization
Organization Name:MOFAZZAL SURAIYA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMIL
Authorized Official - Middle Name:
Authorized Official - Last Name:IMRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-587-8500
Mailing Address - Street 1:1015 OMAHA DR
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-4967
Mailing Address - Country:US
Mailing Address - Phone:404-587-8500
Mailing Address - Fax:770-939-5682
Practice Address - Street 1:2775 CRUSE RD STE 101
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-7141
Practice Address - Country:US
Practice Address - Phone:404-587-8500
Practice Address - Fax:770-939-5682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067-R-0459253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA221998235AMedicaid