1720292584 NPI number — SOUTHLAND HEALTH SERVICES OF GEORGIA, INC.

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 1720292584 NPI number — SOUTHLAND HEALTH SERVICES OF GEORGIA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHLAND HEALTH SERVICES OF GEORGIA, INC.
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:
1720292584
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:
PO BOX 1497
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERNON
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35592-1497
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-695-9800
Provider Business Mailing Address Fax Number:
205-695-7677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1548 HIGHWAY 5 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLIJAY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-273-7477
Provider Business Practice Location Address Fax Number:
706-273-7479
Provider Enumeration Date:
05/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LUNAN
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
423-247-9560

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , 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)





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