=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255719621
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGIA REGENTS UNIVERSITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2015
-----------------------------------------------------
Last Update Date | 05/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3259 VAL TECH RD
-----------------------------------------------------
City | VALDOSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31602-9309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-249-4971
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9444 DRY LAKE RD
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31643-5925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-263-5863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STATEWIDE MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. BILLY NICHOLS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 229-249-4971
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number | RN179363
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------