Basic Information
| Provider Information | |||||||||
| NPI: | 1053772152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | APPLECARE/MEMORIAL IMMEDIATE CARE JOINT VENTURE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | APPLECARE POOLER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 MALL BLVD | ||||||||
| Address2: | SUITE 202E | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314064862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123494945 | ||||||||
| FaxNumber: | 9123494105 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 GRAND CENTRAL BLVD STE 108 | ||||||||
| Address2: | |||||||||
| City: | POOLER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313224148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127481515 | ||||||||
| FaxNumber: | 9127487707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2016 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NASH | ||||||||
| AuthorizedOfficialFirstName: | HEIDI | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9123494945 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.