1326191180 NPI number — PROFESSIONAL RESOURCES MANAGEMENT OF RABUN, LLC

Table of content: (NPI 1326191180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326191180 NPI number — PROFESSIONAL RESOURCES MANAGEMENT OF RABUN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL RESOURCES MANAGEMENT OF RABUN, 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:
MOUNTAIN LAKES MEDICAL CENTER
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:
1326191180
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
162 LEGACY PT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLAYTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30525-5354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-782-3100
Provider Business Mailing Address Fax Number:
706-782-6897

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
162 LEGACY PT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAYTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30525-5354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-782-0401
Provider Business Practice Location Address Fax Number:
706-782-0451
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
KRISTY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
706-782-0400

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  119-621 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10063437 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 293932 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00001559A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0001559S , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51000340 . This is a "BLUE CROSS OF GEORGIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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