Basic Information
| Provider Information | |||||||||
| NPI: | 1770004863 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HUGHSTON CLINIC SOUTHEAST PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 370 | ||||||||
| Address2: | |||||||||
| City: | FORTSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 318080370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064946661 | ||||||||
| FaxNumber: | 7064943008 | ||||||||
| Practice Location | |||||||||
| Address1: | 3443 DICKERSON PIKE STE 190B | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372072533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153018269 | ||||||||
| FaxNumber: | 6157129823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2017 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | FROMKIN | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CRED COORD | ||||||||
| AuthorizedOfficialTelephone: | 7064943071 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | TN | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.