1902009194 NPI number — SOUTHERN FAMILY HEALTHCARE OF EASTMAN INC

Table of content: (NPI 1902009194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902009194 NPI number — SOUTHERN FAMILY HEALTHCARE OF EASTMAN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN FAMILY HEALTHCARE OF EASTMAN 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:
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:
1902009194
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1112 PLAZA AVE STE C
Provider Second Line Business Mailing Address:
PO BOX 789
Provider Business Mailing Address City Name:
EASTMAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31023-9012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-374-1308
Provider Business Mailing Address Fax Number:
478-374-0302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1112 PLAZA AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
EASTMAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31023-9009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-374-1308
Provider Business Practice Location Address Fax Number:
478-374-0302
Provider Enumeration Date:
06/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GLENN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
478-374-1308

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  038495 , 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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