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General NPI Number Information
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NPI Number | 1700042553
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Entity Type | Organization
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Legal Business Name | SOUTHLAND BRANCH FAMILY PRACTICE, LLC
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Dates
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Enumeration Date | 07/31/2008
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Last Update Date | 07/31/2008
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Provider Practice Location Address
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Address Line | 151 MAYO ST
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City | AMERICUS
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State | GA
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Zip | 31709-3735
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Country | US
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Telephone | 229-928-4144
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Fax | 229-928-3410
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Provider Business Mailing Address
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Address Line | PO BOX 546
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City | AMERICUS
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State | GA
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Zip | 31709-0546
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Country | US
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Telephone | 229-928-4144
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Fax | 229-928-3410
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Authorized Official
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Title or Position | NURSE PRACTIONER
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Name | DENISE C LAING
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Credential |
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Telephone | 229-928-4144
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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 | RN127193
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License Number State | GA
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