Basic Information
| Provider Information | |||||||||
| NPI: | 1780224014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HURT | ||||||||
| FirstName: | DEMETRIUS | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 US HIGHWAY 19 S | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317634878 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 940 GA HIGHWAY 96 STE A | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310882587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789887100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2020 | ||||||||
| LastUpdateDate: | 01/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN162310 | GA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.