1205981974 NPI number — LAWRENCE JOEL ARMY HEALTH CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205981974 NPI number — LAWRENCE JOEL ARMY HEALTH CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAWRENCE JOEL ARMY HEALTH CLINIC
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:
1205981974
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
233 PLANTATION DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERDALE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30296-1137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-997-4607
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 HARDEE AVE S. W.
Provider Second Line Business Practice Location Address:
FORT MCPHERSON
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-464-0405
Provider Business Practice Location Address Fax Number:
404-464-0475
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DELERME
Authorized Official First Name:
MELIDA
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
INTERNAL MEDICINE PROVIDER
Authorized Official Telephone Number:
404-464-0405

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  4326 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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