1104033463 NPI number — SATILLA CANCER TREATMENT CENTERS, LLC

Table of content: (NPI 1104033463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104033463 NPI number — SATILLA CANCER TREATMENT CENTERS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SATILLA CANCER TREATMENT CENTERS, 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:
CUREPOINT
Provider Other Organization Name Type Code:
3
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:
1104033463
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2406 BELLEVUE RD
Provider Second Line Business Mailing Address:
#7
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31021-2842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-272-2255
Provider Business Mailing Address Fax Number:
478-275-9134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2406 BELLEVUE RD
Provider Second Line Business Practice Location Address:
#7
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31021-2842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-272-2255
Provider Business Practice Location Address Fax Number:
478-275-9134
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LILLICOTCH
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING OFFICER
Authorized Official Telephone Number:
478-272-2255

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300038888A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 202G708768 . This is a "MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: DQ2362 . This is a "RR MCR" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 11D1096814 . This is a "CLIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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