Healthcare Provider Details

I. General information

NPI: 1144279399
Provider Name (Legal Business Name): LAFAYETTE MEDICAL PROVIDERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201B N MAIN ST
LA FAYETTE GA
30728-2150
US

IV. Provider business mailing address

1201B N MAIN ST
LA FAYETTE GA
30728-2150
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-1506
  • Fax: 706-638-1507
Mailing address:
  • Phone: 706-638-1506
  • Fax: 706-638-1507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. PAMELA ANN BALLINGER
Title or Position: OFFICE MANAGER
Credential:
Phone: 706-638-1506