Provident Healthcare Llc
Geriatric Medicine (Internal Medicine) Physician in Marietta, GA(View on Map)
Legal Business Name
Provident Healthcare Llc
NPI Number
1154706075
NPI Type
Organization
Enumeration Date
07/21/2015
Specialties
(Taxonomies)Name
Code
207RG0300X
207RH0002X
207R00000X
Primary Taxonomy
Yes
No
No
Licenses
State
Georgia
License Number
07088
Contact
Information
Purpose
Mailing
Location
Address
3063 PEACHTREE INDUSTRIAL BLVD
3505 LASSITER FALLS DR NE
City
Duluth
Marietta
State
GA
GA
Postal Code
30097-8639
30062-4199
Country
US
US
Telephone Number
(678) 390-0120
(414) 916-9031
Authorized Official
Name
Dr. Lakshman Dinavahi
Title or Position
CHIEF MEDICAL OFFICER
Telephone Number
(678) 390-0120
Provider data last refreshed from NPPES NPI registry on 11/19/2024
Data last updated by provider on 07/22/2015
Provider Address
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Wellstar Medical Group, Llc
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