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General NPI Number Information
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NPI Number | 1497935407
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Entity Type | Organization
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Legal Business Name | HAZLEHURST PRIMARY CARE, PC
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Dates
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Enumeration Date | 11/07/2007
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Last Update Date | 11/07/2007
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Provider Practice Location Address
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Address Line | 17 JOHNSON ST
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City | HAZLEHURST
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State | GA
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Zip | 31539-6243
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Country | US
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Telephone | 912-375-5507
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Fax | 912-375-2172
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Provider Business Mailing Address
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Address Line | PO BOX 647
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City | HAZLEHURST
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State | GA
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Zip | 31539-0647
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Country | US
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Telephone | 912-375-5507
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Fax | 912-375-2172
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Authorized Official
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Title or Position | DIRECTOR
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Name | SHELLY HARRELL
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Credential | MHSA
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Telephone | 912-538-5508
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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