1992799860 NPI number — PUTNAM COUNTY HEALTH CARE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992799860 NPI number — PUTNAM COUNTY HEALTH CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUTNAM COUNTY HEALTH CARE 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:
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:
1992799860
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 SPARTA HIGHWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EATONTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-485-8573
Provider Business Mailing Address Fax Number:
706-485-8283

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 SPARTA HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EATONTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31024-6093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-485-8573
Provider Business Practice Location Address Fax Number:
706-485-8283
Provider Enumeration Date:
09/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GAINT
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
706-485-8573

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1-117-1769 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000223473A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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