Healthcare Provider Details

I. General information

NPI: 1619966025
Provider Name (Legal Business Name): REDMOND PHYSICIAN PRACTICE COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 12/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 CENTRAL AVE
TRION GA
30753-1125
US

IV. Provider business mailing address

160 CENTRAL AVE
TRION GA
30753-1125
US

V. Phone/Fax

Practice location:
  • Phone: 706-734-7302
  • Fax: 706-734-7356
Mailing address:
  • Phone: 706-734-7302
  • Fax: 706-734-7356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CHUCK LOCKE
Title or Position: VP
Credential:
Phone: 615-373-7604