Healthcare Provider Details

I. General information

NPI: 1902096639
Provider Name (Legal Business Name): DALTON ONSITE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 07/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2613 VALLEY VIEW DR
ROCKY FACE GA
30740-8908
US

IV. Provider business mailing address

2613 VALLEY VIEW DRIVE
ROCKY FACE GA
30740
US

V. Phone/Fax

Practice location:
  • Phone: 706-264-0630
  • Fax:
Mailing address:
  • Phone: 706-264-0630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2396
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4110
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number24831
License Number StateGA

VIII. Authorized Official

Name: MRS. CARA H WATKINS
Title or Position: PARTNER
Credential: PA-C
Phone: 706-264-0630