1811143589 NPI number — NEW HORIZONS FAMILY CLINIC

Table of content: (NPI 1811143589)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811143589 NPI number — NEW HORIZONS FAMILY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW HORIZONS FAMILY CLINIC
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:
FAITH HEALTHCARE SERVICES, INC.
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:
1811143589
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3725 ZOAR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SNELLVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30039-6134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-248-1637
Provider Business Mailing Address Fax Number:
770-248-1638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3725 ZOAR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SNELLVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30039-6134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-248-1637
Provider Business Practice Location Address Fax Number:
770-248-1638
Provider Enumeration Date:
08/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SAMUELS
Authorized Official First Name:
ANGELLA
Authorized Official Middle Name:
Authorized Official Title or Position:
FAMILY NURSE PRACTITIONER
Authorized Official Telephone Number:
770-248-1637

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  133706NP , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1811143589 . This is a "MEDICARE GROUP NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 511G700793 . This is a "MEDICARE GROUP PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 844105153A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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