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General NPI Number Information
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NPI Number | 1508584319
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Entity Type | Organization
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Legal Business Name | SOUTHERN PRIMARY CARE AND BEHAVIORAL HEALTH SERVICES, LLC
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Dates
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Enumeration Date | 08/17/2022
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Last Update Date | 08/17/2022
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Provider Practice Location Address
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Address Line | 224 PEACHTREE ST
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City | BAXLEY
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State | GA
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Zip | 31513-8079
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Country | US
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Telephone | 912-278-0410
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Fax |
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Provider Business Mailing Address
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Address Line | 64 MONY ST
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City | BAXLEY
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State | GA
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Zip | 31513-7135
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Country | US
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Telephone | 912-278-0410
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KNICOLE ANN LEE
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Credential |
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Telephone | 912-278-0410
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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