Basic Information
Provider Information | |||||||||
NPI: | 1316994833 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LOWNDES COUNTY HEALTH SERVICES LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PARKWOOD DEVELOPMENT CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 211 E DOYLE ST | ||||||||
Address2: |   | ||||||||
City: | TOCCOA | ||||||||
State: | GA | ||||||||
PostalCode: | 305772960 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7068868493 | ||||||||
FaxNumber: | 7068272048 | ||||||||
Practice Location | |||||||||
Address1: | 1501 N LEE ST | ||||||||
Address2: |   | ||||||||
City: | VALDOSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 316023309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2292426268 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2006 | ||||||||
LastUpdateDate: | 08/21/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PRUITT | ||||||||
AuthorizedOfficialFirstName: | NEIL | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | CHAIRMAN AND CEO | ||||||||
AuthorizedOfficialTelephone: | 7702796200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 2-092-532 | GA | Y |   | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |   |
ID Information
ID | Type | State | Issuer | Description | 00142348A | 05 | GA |   | MEDICAID |