Basic Information
| Provider Information | |||||||||
| NPI: | 1427057363 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONAL RESOURCE MGMT OF RABUN, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MOUNTAIN LAKES MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 196 RIDGECREST CIR | ||||||||
| Address2: | SURGICAL SERVICE | ||||||||
| City: | CLAYTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305254111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067824233 | ||||||||
| FaxNumber: | 7067820451 | ||||||||
| Practice Location | |||||||||
| Address1: | 196 RIDGECREST CIR | ||||||||
| Address2: | SURGICAL SERVICE | ||||||||
| City: | CLAYTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305254111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067824233 | ||||||||
| FaxNumber: | 7067820451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 08/31/2010 | ||||||||
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| AuthorizedOfficialLastName: | INGRAM | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7067824233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 62897 | GA | Y | Hospitals | General Acute Care Hospital |
No ID Information.