Healthcare Provider Details

I. General information

NPI: 1619118015
Provider Name (Legal Business Name): GEORGIA MEDPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2009
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 CHESTNUT ST SE SUITE A
GAINESVILLE GA
30501-6909
US

IV. Provider business mailing address

PO BOX 2306
GAINESVILLE GA
30503-2306
US

V. Phone/Fax

Practice location:
  • Phone: 770-535-2601
  • Fax: 770-535-2602
Mailing address:
  • Phone: 770-535-2601
  • Fax: 770-535-2602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number069-19
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MR. ZACHARY WILLIAMS NIX
Title or Position: CO-OWNER
Credential:
Phone: 770-535-2601