Healthcare Provider Details

I. General information

NPI: 1316683212
Provider Name (Legal Business Name): MOM-YKK CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3340 CHESTNEY RD
MACON GA
31217-5502
US

IV. Provider business mailing address

124 3RD ST
MACON GA
31201-3404
US

V. Phone/Fax

Practice location:
  • Phone: 478-972-8900
  • Fax:
Mailing address:
  • Phone: 478-751-2925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LEONARD BEVILL
Title or Position: PRESIDENT/CEO
Credential:
Phone: 478-751-2925