1346451366 NPI number — JESUS IS LORD HEALTHCARE SERVICES, INC.

Table of content: (NPI 1346451366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346451366 NPI number — JESUS IS LORD HEALTHCARE SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JESUS IS LORD HEALTHCARE SERVICES, 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:
1346451366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2764 TOBACCO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HEPHZIBAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30815-7014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-790-5836
Provider Business Mailing Address Fax Number:
706-790-0767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2764 TOBACCO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HEPHZIBAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30815-7014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-790-5836
Provider Business Practice Location Address Fax Number:
706-790-0767
Provider Enumeration Date:
05/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
DOROTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
706-790-0767

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  021-R-0019 , 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)

  • Identifier: 000804889B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000804889H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000804889C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000804889G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000804889K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000804889D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000804889A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com