=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669912671
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERIC TURNER FAMILY COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2017
-----------------------------------------------------
Last Update Date | 02/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 525 W 13TH ST NE 405
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30165-2698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-584-7234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 525 W 13TH ST NE 405
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30165-2698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-584-7234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ERIC BERNARD TURNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-766-4780
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number | 056276564
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------