Provider Demographics
NPI:1649851627
Name:TBI3 GEORGIA LLC
Entity type:Organization
Organization Name:TBI3 GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-648-5161
Mailing Address - Street 1:300 COLONIAL CENTER PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4892
Mailing Address - Country:US
Mailing Address - Phone:936-648-5161
Mailing Address - Fax:
Practice Address - Street 1:4319 COVINGTON HIGHWAY DECATUR
Practice Address - Street 2:STE 209
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035
Practice Address - Country:US
Practice Address - Phone:678-977-1792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center