Healthcare Provider Details

I. General information

NPI: 1568662245
Provider Name (Legal Business Name): TOCCOA CLINIC MEDICAL ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 BIG A ROAD
TOCCOA GA
30577-6000
US

IV. Provider business mailing address

PO BOX 2153 DEPT 3423
BIRMINGHAM AL
35287-3423
US

V. Phone/Fax

Practice location:
  • Phone: 706-886-3148
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0835590002
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerMEDICARE DME SUPPLIER NUM

VIII. Authorized Official

Name: MR. RAY BRUELAND
Title or Position: DIRECTOR OF BUSINESS
Credential:
Phone: 706-886-7537