Healthcare Provider Details

I. General information

NPI: 1780244301
Provider Name (Legal Business Name): HEART OF GEORGIA PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 PLAZA AVE STE C
EASTMAN GA
31023-6786
US

IV. Provider business mailing address

911 PLAZA AVE STE C
EASTMAN GA
31023-6786
US

V. Phone/Fax

Practice location:
  • Phone: 478-374-5774
  • Fax:
Mailing address:
  • Phone: 478-374-5774
  • Fax: 912-374-9112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. AMY H CRAVEY
Title or Position: OWNER
Credential: FNP-C
Phone: 478-374-5774