1992999205 NPI number — COFFEE REGIONAL MEDICAL CENTER

Table of content: MRS. VERDELLE GLOVER CHAMBLISS PHYSICAL THERAPIST (NPI 1740397264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992999205 NPI number — COFFEE REGIONAL MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COFFEE REGIONAL MEDICAL CENTER
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:
1992999205
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 OCILLA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLAS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31533-2207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-384-1900
Provider Business Mailing Address Fax Number:
912-389-2105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 OCILLA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLAS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31533-2207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-384-1900
Provider Business Practice Location Address Fax Number:
912-389-2105
Provider Enumeration Date:
08/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LORD
Authorized Official First Name:
ELAINE
Authorized Official Middle Name:
F
Authorized Official Title or Position:
MEDICAL STAFF ASSISTANT
Authorized Official Telephone Number:
912-383-5623

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  03941 , 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)





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