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General NPI Number Information
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NPI Number | 1346590148
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Entity Type | Organization
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Legal Business Name | PROVIDENCE FAMILY MEDICINE CLINIC, INC
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Dates
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Enumeration Date | 09/19/2012
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Last Update Date | 09/19/2012
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Provider Practice Location Address
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Address Line | 1787 BROAD STREET PROVIDENCE FAMILY MEDICINE CLINIC, INC
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City | LUMPKIN
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State | GA
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Zip | 31815
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Country | US
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Telephone | 703-593-6154
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Fax |
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Provider Business Mailing Address
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Address Line | 1787 BROAD ST. P.O. BOX 685
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City | LUMPKIN
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State | GA
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Zip | 31815
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Country | US
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Telephone | 703-593-6154
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. SARITA DARLENE MOBLEY
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Credential | M.D., MPH, MS
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Telephone | 703-593-6154
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 046872
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License Number State | GA
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