Healthcare Provider Details

I. General information

NPI: 1225100589
Provider Name (Legal Business Name): MARION COUNTY COMMISSIONER OF ROADS AND REVENUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BURKHALTER AVE
BUENA VISTA GA
31803-9701
US

IV. Provider business mailing address

PO BOX 702
BUENA VISTA GA
31803-0702
US

V. Phone/Fax

Practice location:
  • Phone: 229-314-4569
  • Fax: 229-649-2033
Mailing address:
  • Phone: 229-649-3025
  • Fax: 229-649-2033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number096-01
License Number StateGA

VIII. Authorized Official

Name: MARK C DEJONG
Title or Position: EMS DIRECTOR
Credential:
Phone: 229-314-4569