1336395615 NPI number — LAURENS COUNTY BOARD OF HEALTH

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 1336395615 NPI number — LAURENS COUNTY BOARD OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAURENS COUNTY BOARD OF HEALTH
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:
1336395615
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2121B BELLEVUE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31021-2952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-275-6545
Provider Business Mailing Address Fax Number:
478-275-6567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 ACADEMY AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31021-4083
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-296-2040
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
WILKES
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
478-275-6545

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000297932F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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