1760612055 NPI number — THE FAMILY HEALTH CENTERS OF GEORGIA, INC

Table of content: (NPI 1760612055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760612055 NPI number — THE FAMILY HEALTH CENTERS OF GEORGIA, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE FAMILY HEALTH CENTERS OF GEORGIA, 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:
1760612055
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2011 BOLTON ROAD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30318-1137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-799-0851
Provider Business Mailing Address Fax Number:
404-794-4798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2011 BOLTON ROAD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30318-1137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-799-0851
Provider Business Practice Location Address Fax Number:
404-794-4798
Provider Enumeration Date:
07/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BROOKS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT, CEO
Authorized Official Telephone Number:
404-752-1400

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000437478M , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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