Healthcare Provider Details

I. General information

NPI: 1457646770
Provider Name (Legal Business Name): FAMILY TOTAL HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 JACKSON ST
VIDALIA GA
30474-4720
US

IV. Provider business mailing address

PO BOX 627
VIDALIA GA
30475-0627
US

V. Phone/Fax

Practice location:
  • Phone: 912-537-2564
  • Fax: 912-538-9391
Mailing address:
  • Phone: 912-537-2564
  • Fax: 912-538-9391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number122840
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR001572
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number47233
License Number StateGA

VIII. Authorized Official

Name: MR. GARLAND MARTIN
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 912-367-5525