1710972773 NPI number — FAYETTE COUNTY BOARD OF HEALTH

Table of content: (NPI 1710972773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710972773 NPI number — FAYETTE COUNTY BOARD OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAYETTE COUNTY BOARD OF HEALTH
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:
1710972773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
140 STONEWALL AVE W
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-1520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-461-1178
Provider Business Mailing Address Fax Number:
770-460-2457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 STONEWALL AVE W
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-1520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-305-5416
Provider Business Practice Location Address Fax Number:
770-305-5422
Provider Enumeration Date:
09/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ELLINGTON
Authorized Official First Name:
RHONDA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
706-298-7732

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP0905X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000456453E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000784352C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000052093E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000784352A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000456453W , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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