Healthcare Provider Details

I. General information

NPI: 1740446905
Provider Name (Legal Business Name): DDEAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 08/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W HOSPITAL RD
FORT GORDON GA
30905-5741
US

IV. Provider business mailing address

300 W HOSPITAL RD
FORT GORDON GA
30905-5741
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-9253
  • Fax: 706-787-9356
Mailing address:
  • Phone: 706-787-9253
  • Fax: 706-787-9356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberLPN024837
License Number StateGA

VIII. Authorized Official

Name: MRS. CAROLYN L. JONES
Title or Position: LPN
Credential:
Phone: 706-787-9253