Healthcare Provider Details

I. General information

NPI: 1851636070
Provider Name (Legal Business Name): BOSTON FAMILY CARE CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2012
Last Update Date: 01/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 N MAIN ST
BOSTON GA
31626-2257
US

IV. Provider business mailing address

PO BOX 1276
THOMASVILLE GA
31799-1276
US

V. Phone/Fax

Practice location:
  • Phone: 229-236-0861
  • Fax: 229-236-0871
Mailing address:
  • Phone: 229-236-0861
  • Fax: 229-236-0871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK ALLEN LEE
Title or Position: PRESIDENT
Credential: MD
Phone: 229-200-4019