Healthcare Provider Details

I. General information

NPI: 1245245620
Provider Name (Legal Business Name): LORRAINE DRIVER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 12/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 2ND ST STE 105
MONROE GA
30655-2391
US

IV. Provider business mailing address

PO BOX 1807
MONROE GA
30655-6807
US

V. Phone/Fax

Practice location:
  • Phone: 770-207-5300
  • Fax: 888-843-1625
Mailing address:
  • Phone: 770-207-5300
  • Fax: 888-843-1625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. LORRAINE DRIVER
Title or Position: CEO
Credential:
Phone: 770-207-5300