=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134908098
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTMAN MEDICAL CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2023
-----------------------------------------------------
Last Update Date | 10/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 821 PLAZA AVE
-----------------------------------------------------
City | EASTMAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31023-6757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-448-4435
-----------------------------------------------------
Fax | 478-374-0337
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 821 PLAZA AVE
-----------------------------------------------------
City | EASTMAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31023-6757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-448-4435
-----------------------------------------------------
Fax | 478-374-0337
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO/AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | JAN HAMRICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 478-448-4435
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------