Basic Information
| Provider Information | |||||||||
| NPI: | 1336395615 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAURENS COUNTY BOARD OF HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAURENS COUNTY HEALTH DEPARTMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121B BELLEVUE RD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782756545 | ||||||||
| FaxNumber: | 4782756567 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 ACADEMY AVE STE A | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310214083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782962040 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 08/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | WILKES | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4782756545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 000297932F | 05 | GA | MEDICAID |