Basic Information
| Provider Information | |||||||||
| NPI: | 1073829073 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAGLES LANDING FAMILY PRACTICE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 HIGHWAY 155 N | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302524806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784900341 | ||||||||
| FaxNumber: | 6784900349 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 HIGHWAY 155 N | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302524806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784900341 | ||||||||
| FaxNumber: | 6784900349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2010 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | MITCHAM | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7709140116 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.