Provider Demographics
NPI:1053787358
Name:CLINICA UNION
Entity type:Organization
Organization Name:CLINICA UNION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-321-4692
Mailing Address - Street 1:3369 BUFORD HWY NE
Mailing Address - Street 2:SUITE 810
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3722
Mailing Address - Country:US
Mailing Address - Phone:404-321-4692
Mailing Address - Fax:
Practice Address - Street 1:861 HOLCOMB BRIDGE RD
Practice Address - Street 2:STE 200
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1900
Practice Address - Country:US
Practice Address - Phone:770-992-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty