Healthcare Provider Details

I. General information

NPI: 1639580186
Provider Name (Legal Business Name): MUMFORD TELEHEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2014
Last Update Date: 05/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4113 FENWICK VILLAGE DR
SAVANNAH GA
31419-5513
US

IV. Provider business mailing address

4113 FENWICK VILLAGE DR
SAVANNAH GA
31419-5513
US

V. Phone/Fax

Practice location:
  • Phone: 912-844-6497
  • Fax:
Mailing address:
  • Phone: 912-844-6497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberRN168735
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberRN168735
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberRN168735
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberRN168735
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberRN168735
License Number StateGA
# 6
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberRN168735
License Number StateGA

VIII. Authorized Official

Name: MS. PENNICA MUMFORD MUMFORD
Title or Position: CEO
Credential: RN
Phone: 912-844-6497