1215171459 NPI number — FAMILYCARE MEDICAL, LLC

Table of content: (NPI 1215171459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215171459 NPI number — FAMILYCARE MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILYCARE MEDICAL, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215171459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 783
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REX
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30273-0783
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-968-1997
Provider Business Mailing Address Fax Number:
770-968-1918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6685 MERCHANTS WAY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MORROW
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30260-2342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-968-1997
Provider Business Practice Location Address Fax Number:
770-968-1918
Provider Enumeration Date:
04/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
THEDFORD
Authorized Official First Name:
VICTORIA
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-968-1997

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  054039 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 054039 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 054039 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 187347049E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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