Healthcare Provider Details

I. General information

NPI: 1275751448
Provider Name (Legal Business Name): ATHENS MODEL NEIGHBORHOOD HEALTH CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 MCKINLEY DRIVE
ATHENS GA
30601
US

IV. Provider business mailing address

402 MCKINLEY DRIVE
ATHENS GA
30601
US

V. Phone/Fax

Practice location:
  • Phone: 706-543-1145
  • Fax: 706-549-0056
Mailing address:
  • Phone: 706-543-1145
  • Fax: 706-549-0056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: CAROL STEPHENS
Title or Position: OFFICE MANAGER
Credential:
Phone: 706-543-1145