Healthcare Provider Details

I. General information

NPI: 1275440455
Provider Name (Legal Business Name): REBEKAH LAROCHE
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2747 4TH ST
BRUNSWICK GA
31520-3714
US

IV. Provider business mailing address

230 E RIDGE DR
BRUNSWICK GA
31525-8352
US

V. Phone/Fax

Practice location:
  • Phone: 912-264-3961
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN311748
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: