Provider Demographics
NPI:1003087685
Name:ADVANCED MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:ADVANCED MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:678-985-7246
Mailing Address - Street 1:PO BOX 1860
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29834-1860
Mailing Address - Country:US
Mailing Address - Phone:803-593-3411
Mailing Address - Fax:678-689-1459
Practice Address - Street 1:450 OLD PEACHTREE RD NW
Practice Address - Street 2:SUITE 102
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-7289
Practice Address - Country:US
Practice Address - Phone:877-645-3506
Practice Address - Fax:888-273-1488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC91813336C0003X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy