Healthcare Provider Details

I. General information

NPI: 1053458190
Provider Name (Legal Business Name): UNADILLA HEALTH CARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2858 PINE STREET
UNADILLA GA
31091
US

IV. Provider business mailing address

2858 PINE STREET
UNADILLA GA
31091
US

V. Phone/Fax

Practice location:
  • Phone: 478-627-3263
  • Fax: 478-627-9714
Mailing address:
  • Phone: 478-627-3263
  • Fax: 478-627-9714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number030206
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN011230
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN013043
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: AMY L LANCASTER
Title or Position: CFO
Credential:
Phone: 478-627-3263