Basic Information
Provider Information | |||||||||
NPI: | 1811250244 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CANDID MEDICAL GROUP LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6525 PROFESSIONAL PL | ||||||||
Address2: | SUITE C | ||||||||
City: | RIVERDALE | ||||||||
State: | GA | ||||||||
PostalCode: | 302742519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709941250 | ||||||||
FaxNumber: | 7709941295 | ||||||||
Practice Location | |||||||||
Address1: | 6525 PROFESSIONAL PL | ||||||||
Address2: | SUITE C | ||||||||
City: | RIVERDALE | ||||||||
State: | GA | ||||||||
PostalCode: | 302742519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709941250 | ||||||||
FaxNumber: | 7709941295 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2012 | ||||||||
LastUpdateDate: | 06/20/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CAUDILL | ||||||||
AuthorizedOfficialFirstName: | BRYAN | ||||||||
AuthorizedOfficialMiddleName: | PRESTON | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
AuthorizedOfficialTelephone: | 4047189969 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Pain |
No ID Information.