1578590972 NPI number — AMPUTEE PROSTHETIC CLINIC, CO.

Table of content: (NPI 1578590972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578590972 NPI number — AMPUTEE PROSTHETIC CLINIC, CO.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMPUTEE PROSTHETIC CLINIC, CO.
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:
1578590972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4900 MERCER UNIVERSITY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31210-6239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-474-5678
Provider Business Mailing Address Fax Number:
478-474-5018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
805 CAMDEN WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIFTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31794-8093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-387-6600
Provider Business Practice Location Address Fax Number:
229-387-7800
Provider Enumeration Date:
06/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
PAM
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OFF. MANAGER/OWNER
Authorized Official Telephone Number:
478-474-5678

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6016598 . This is a "DEPT. OF LABOR" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 408774069A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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