Basic Information
| Provider Information | |||||||||
| NPI: | 1386193571 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TLC OF GEORGIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2620 ELM HILL PIKE | ||||||||
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| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372143108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154254200 | ||||||||
| FaxNumber: | 6158915244 | ||||||||
| Practice Location | |||||||||
| Address1: | 4321 HARTLEY BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312165641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787882046 | ||||||||
| FaxNumber: | 4787882047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2016 | ||||||||
| LastUpdateDate: | 12/21/2016 | ||||||||
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| AuthorizedOfficialLastName: | WATKINS | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 6154254200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1750677241 | 01 | GA | GROUP NPI | OTHER |