=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073269536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NG CLINICAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2022
-----------------------------------------------------
Last Update Date | 03/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 136 INDUSTRIAL BLVD STE A
-----------------------------------------------------
City | ELLIJAY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30540-3713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-276-6550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 136 INDUSTRIAL BLVD STE A
-----------------------------------------------------
City | ELLIJAY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30540-3713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-276-6550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | STEVEN PURVIS
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 706-273-6198
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------