1821540048 NPI number — THE LITTLE CLINIC OF GEORGIA LLC

Table of content: (NPI 1821540048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821540048 NPI number — THE LITTLE CLINIC OF GEORGIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE LITTLE CLINIC OF GEORGIA LLC
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:
1821540048
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2620 ELM HILL PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37214-3108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-425-4200
Provider Business Mailing Address Fax Number:
615-891-5244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1751 NEWNAN CROSSINGS BOULAVARD EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWNAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-423-5854
Provider Business Practice Location Address Fax Number:
678-423-5855
Provider Enumeration Date:
11/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WATKINS
Authorized Official First Name:
MARC
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CMO
Authorized Official Telephone Number:
615-425-4200

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1750677241 . This is a "GROUP NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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