1134519077 NPI number — MADE WHOLE HEALTHCARE SOLUTIONS, INC

Table of content: (NPI 1134519077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134519077 NPI number — MADE WHOLE HEALTHCARE SOLUTIONS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MADE WHOLE HEALTHCARE SOLUTIONS, 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:
1134519077
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 71802
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31708-1802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-330-8496
Provider Business Mailing Address Fax Number:
229-888-7421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2709 GILLIONVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31721-6271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-483-0020
Provider Business Practice Location Address Fax Number:
229-483-0021
Provider Enumeration Date:
01/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
FORTSON
Authorized Official First Name:
NEDRA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
770-330-8496

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  RN131505 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LA2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 217951 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20250I9514 . This is a "MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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