Healthcare Provider Details

I. General information

NPI: 1013949247
Provider Name (Legal Business Name): AMPUTEE PROSTHETIC CLINIC, CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 MERCER UNIVERSITY DR
MACON GA
31210-6239
US

IV. Provider business mailing address

4900 MERCER UNIVERSITY DR
MACON GA
31210-6239
US

V. Phone/Fax

Practice location:
  • Phone: 478-474-5678
  • Fax: 478-474-5018
Mailing address:
  • Phone: 478-474-5678
  • Fax: 478-474-5018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberCP2910
License Number StateGA

VIII. Authorized Official

Name: MRS. PAM S YOUNG
Title or Position: OFF. MANAGER/BUSINESS OWNER
Credential:
Phone: 478-474-5678