Basic Information
Provider Information | |||||||||
NPI: | 1043440340 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARECONNECT HEALTH, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CARECONNECT CONVENIENT CARE AND PEDIATRICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 5610 | ||||||||
Address2: |   | ||||||||
City: | CORDELE | ||||||||
State: | GA | ||||||||
PostalCode: | 310101514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2292738881 | ||||||||
FaxNumber: | 2292738985 | ||||||||
Practice Location | |||||||||
Address1: | 817 GRIFFIN AVE | ||||||||
Address2: |   | ||||||||
City: | EASTMAN | ||||||||
State: | GA | ||||||||
PostalCode: | 310236718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4783741801 | ||||||||
FaxNumber: | 4784484586 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2009 | ||||||||
LastUpdateDate: | 03/31/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOUNG | ||||||||
AuthorizedOfficialFirstName: | LINDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 2292738881 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/31/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 312980311A | 05 | GA |   | MEDICAID |