1235547431 NPI number — LAKE OCONEE URGENT AND SPECIALTY CARE CENTER

Table of content: (NPI 1235547431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235547431 NPI number — LAKE OCONEE URGENT AND SPECIALTY CARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE OCONEE URGENT AND SPECIALTY CARE CENTER
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:
1235547431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1881 LANCASTER DR SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONYERS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30013-6440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-405-7596
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 HARMONY XING
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
EATONTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31024-9522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-484-0884
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2014

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARDSON
Authorized Official First Name:
EDDIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN/PRACTICE OWNER
Authorized Official Telephone Number:
706-484-0884

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  7235 , 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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