Provider Demographics
NPI:1962767954
Name:DAEC, INC
Entity type:Organization
Organization Name:DAEC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:RUTLEDGE
Authorized Official - Last Name:FORNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-816-7900
Mailing Address - Street 1:PO BOX 52226
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30355-0226
Mailing Address - Country:US
Mailing Address - Phone:404-816-7900
Mailing Address - Fax:404-816-7929
Practice Address - Street 1:4939 LOWER ROSWELL RD
Practice Address - Street 2:SUITE 104A
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4338
Practice Address - Country:US
Practice Address - Phone:404-816-7900
Practice Address - Fax:404-816-7929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty