Healthcare Provider Details

I. General information

NPI: 1124074992
Provider Name (Legal Business Name): LAFAYETTE AFTER HOURS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 E VILLANOW ST
LA FAYETTE GA
30728-2618
US

IV. Provider business mailing address

615 E VILLANOW ST
LA FAYETTE GA
30728-2618
US

V. Phone/Fax

Practice location:
  • Phone: 423-495-4839
  • Fax: 423-495-7887
Mailing address:
  • Phone: 423-495-4839
  • Fax: 423-495-7887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ALOYSIUS T MANGAN
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 706-638-6016