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General NPI Number Information
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NPI Number | 1235547431
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Entity Type | Organization
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Legal Business Name | LAKE OCONEE URGENT AND SPECIALTY CARE CENTER
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Dates
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Enumeration Date | 07/31/2014
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Last Update Date | 07/31/2014
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Provider Practice Location Address
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Address Line | 105 HARMONY XING SUITE 3
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City | EATONTON
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State | GA
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Zip | 31024-9522
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Country | US
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Telephone | 706-484-0884
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Fax |
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Provider Business Mailing Address
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Address Line | 1881 LANCASTER DR SE
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City | CONYERS
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State | GA
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Zip | 30013-6440
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Country | US
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Telephone | 404-405-7596
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN/PRACTICE OWNER
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Name | DR. EDDIE RICHARDSON
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Credential | M.D.
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Telephone | 706-484-0884
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 7235
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License Number State | GA
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