1457797938 NPI number — PERFECT HEALTH ALWAYS ON CALL, LLC

Table of content: (NPI 1457797938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457797938 NPI number — PERFECT HEALTH ALWAYS ON CALL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERFECT HEALTH ALWAYS ON CALL, 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:
PERFECT HEALTH URGENT CARE
Provider Other Organization Name Type Code:
5
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:
1457797938
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 509
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROVETOWN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-760-7607
Provider Business Mailing Address Fax Number:
706-760-7605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4244 WASHINGTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-760-7607
Provider Business Practice Location Address Fax Number:
706-760-7605
Provider Enumeration Date:
05/11/2013

Additional Information

Authorized Official

Authorized Official Last Name:
COON
Authorized Official First Name:
TROY
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
762-218-3627

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , with the licence number:  056422 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332900000X , with the licence number: 056422 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 202G706320 . This is a "MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003164473A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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