Basic Information
| Provider Information | |||||||||
| NPI: | 1366576928 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAURENS COUNTY BAORD OF HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHILDRENS MEDICAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2505 BELLEVUE ROAD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782756545 | ||||||||
| FaxNumber: | 4782755117 | ||||||||
| Practice Location | |||||||||
| Address1: | 2505 BELLEVUE ROAD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782756545 | ||||||||
| FaxNumber: | 4782755117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 07/16/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | WILKES | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4782756545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 000611553B | 05 | GA | MEDICAID |