Provider Demographics
NPI:1366711202
Name:AAA WATERFORD MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:AAA WATERFORD MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SALINAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-992-9130
Mailing Address - Street 1:3069 AMWILER RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30360-2825
Mailing Address - Country:US
Mailing Address - Phone:678-969-9920
Mailing Address - Fax:678-969-9919
Practice Address - Street 1:3069 AMWILER RD
Practice Address - Street 2:SUITE 2
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30360-2825
Practice Address - Country:US
Practice Address - Phone:678-969-9920
Practice Address - Fax:678-969-9919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA07035065261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center