Basic Information
| Provider Information | |||||||||
| NPI: | 1912519505 | ||||||||
| EntityType: | 2 | ||||||||
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| 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: | 7065700220 | ||||||||
| FaxNumber: | 7064943008 | ||||||||
| Practice Location | |||||||||
| Address1: | 819 E OAK ST STE A | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347445842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074760780 | ||||||||
| FaxNumber: | 4074760785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2020 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | FROMKIN | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7065700220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HUGHSTON CLINIC SOUTHEAST PC | ||||||||
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| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.