1457633695 NPI number — TIFT COUNTY BOARD OF HEALTH D/B/A DIVERSIFIED ENTERPRISES

Table of content: ALISYN VICTORIA GRAESSER DPT (NPI 1972028348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457633695 NPI number — TIFT COUNTY BOARD OF HEALTH D/B/A DIVERSIFIED ENTERPRISES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIFT COUNTY BOARD OF HEALTH D/B/A DIVERSIFIED ENTERPRISES
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:
1457633695
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
192 VIRGINIA AVE S
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
TIFTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31794-8074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-386-3560
Provider Business Mailing Address Fax Number:
229-386-7156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
192 VIRGINIA AVE S
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
TIFTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31794-8074
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-386-3560
Provider Business Practice Location Address Fax Number:
229-386-7156
Provider Enumeration Date:
09/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
DURDEN
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
Authorized Official Title or Position:
WEB PORTAL MANAGER
Authorized Official Telephone Number:
229-386-3122

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000609771BL , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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