1184117863 NPI number — WARNER ROBINS PRIMARY CARE, LLC

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 1184117863 NPI number — WARNER ROBINS PRIMARY CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WARNER ROBINS PRIMARY CARE, 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:
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:
1184117863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 46
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KATHLEEN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31047-0046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-689-5190
Provider Business Mailing Address Fax Number:
888-813-6815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 BORDERS WAY STE 500
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARNER ROBINS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31088-8967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-333-2182
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/07/2018

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
DARLA
Authorized Official Middle Name:
NICOLE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
478-352-0422

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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