Healthcare Provider Details

I. General information

NPI: 1679132922
Provider Name (Legal Business Name): JUDY B BAIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 HARWELL AVE STE 236
LAGRANGE GA
30240-3132
US

IV. Provider business mailing address

104 HARWELL AVE STE 236
LAGRANGE GA
30240-3132
US

V. Phone/Fax

Practice location:
  • Phone: 706-885-0111
  • Fax: 706-885-0607
Mailing address:
  • Phone: 706-885-0111
  • Fax: 706-885-0607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROXIE MOTON
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 706-594-6073