1578758553 NPI number — JACKSONS POINT OF LIGHT FAMILY MEDICINE INC.

Table of content: (NPI 1578758553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578758553 NPI number — JACKSONS POINT OF LIGHT FAMILY MEDICINE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSONS POINT OF LIGHT FAMILY MEDICINE 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:
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:
1578758553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1045
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHENIX CITY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36868-1045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-291-5255
Provider Business Mailing Address Fax Number:
877-395-0710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1810 STADIUM DR
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
PHENIX CITY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36867-3177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-291-5255
Provider Business Practice Location Address Fax Number:
877-395-0710
Provider Enumeration Date:
09/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
DERRIC
Authorized Official Middle Name:
N
Authorized Official Title or Position:
ADMINISTRATON/COO
Authorized Official Telephone Number:
334-291-5255

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 053082406B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD 26806 . This is a "AL LICENSE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 101067 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 056705 . This is a "GA LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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