Basic Information
| Provider Information | |||||||||
| NPI: | 1528298668 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONG COUNTY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 865 S 1ST ST | ||||||||
| Address2: | |||||||||
| City: | JESUP | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315450210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124276811 | ||||||||
| FaxNumber: | 9125303495 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 E CYPRESS ST | ||||||||
| Address2: | BLDG A | ||||||||
| City: | LUDOWICI | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123024067 | ||||||||
| FaxNumber: | 9123024068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2009 | ||||||||
| LastUpdateDate: | 07/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | IERARDI | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9125303302 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOSPITAL AUTHORITY OF WAYNE COUNTY GEORGIA | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.