=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518398049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORMAN PARK FAMILY MEDICINE CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2013
-----------------------------------------------------
Last Update Date | 09/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 139 EAST BROAD STREET
-----------------------------------------------------
City | NORMAN PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-769-3500
-----------------------------------------------------
Fax | 229-769-3501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2876
-----------------------------------------------------
City | MOULTRIE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31776-2876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-769-3500
-----------------------------------------------------
Fax | 229-769-3501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JAMES L MATNEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 229-985-3420
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------