Healthcare Provider Details

I. General information

NPI: 1871508606
Provider Name (Legal Business Name): NOVA FAMILY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 S ISABELLA ST SUITE C
SYLVESTER GA
31791-7554
US

IV. Provider business mailing address

PO BOX 465
SYLVESTER GA
31791-0465
US

V. Phone/Fax

Practice location:
  • Phone: 229-776-9143
  • Fax:
Mailing address:
  • Phone: 229-776-9143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberBC4653247
License Number StateGA

VIII. Authorized Official

Name: DR. MARTHA LOUISE COOPER
Title or Position: OWNER
Credential: M.D.
Phone: 229-776-9143