1124433768 NPI number — TOTAL CARE FAMILY MEDICINE PC

Table of content: MS. AMANDA LEA GORMAN (NPI 1669691804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124433768 NPI number — TOTAL CARE FAMILY MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOTAL CARE FAMILY MEDICINE PC
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:
1124433768
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2022 FAIRBURN RD
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
DOUGLASVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30135-1062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
770-942-1699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 CARROLLTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30179-3796
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-942-1044
Provider Business Practice Location Address Fax Number:
770-942-1699
Provider Enumeration Date:
06/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BURTON
Authorized Official First Name:
KELVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
770-942-1044

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  032101 , 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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