1205585064 NPI number — I V CARE OF MIDDLE GEORGIA INC

Table of content: JACOB MICHAEL PLETT O.D. (NPI 1700105608)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205585064 NPI number — I V CARE OF MIDDLE GEORGIA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
I V CARE OF MIDDLE GEORGIA INC
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:
6
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:
1205585064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
718 MEDICAL CENTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EASTMAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31023-6736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-374-6662
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1213 MERCHANT WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30458-0876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-374-6662
Provider Business Practice Location Address Fax Number:
478-374-6663
Provider Enumeration Date:
03/21/2022

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSON
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
T
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
478-374-6662

Provider Taxonomy Codes

  • Taxonomy code: 261QI0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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