=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447688262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOWN CENTRAL INSURANCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2013
-----------------------------------------------------
Last Update Date | 10/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 748 STONECYPHER ST
-----------------------------------------------------
City | CORNELIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30531-2456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-778-6268
-----------------------------------------------------
Fax | 706-778-6271
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 748 STONECYPHER ST
-----------------------------------------------------
City | CORNELIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30531-2456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-778-6268
-----------------------------------------------------
Fax | 706-778-6271
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL
-----------------------------------------------------
Name | PHAILOTH LOONUBON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-778-6268
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251X00000X
-----------------------------------------------------
Taxonomy Name | Supports Brokerage Agency
-----------------------------------------------------
License Number | 15985727
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------