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General NPI Number Information
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NPI Number | 1710379649
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Entity Type | Organization
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Legal Business Name | CENTRAL GEORGIA TOTAL CARE, LLC
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Dates
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Enumeration Date | 03/02/2015
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Last Update Date | 03/02/2015
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Provider Practice Location Address
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Address Line | 644 TALLULAH TRL
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City | WARNER ROBINS
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State | GA
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Zip | 31088-7625
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Country | US
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Telephone | 478-333-2100
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Fax | 478-333-5201
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Provider Business Mailing Address
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Address Line | 644 TALLULAH TRL
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City | WARNER ROBINS
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State | GA
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Zip | 31088-7625
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Country | US
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Telephone | 478-333-2100
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Fax | 478-333-5201
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Authorized Official
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Title or Position | OWNER
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Name | RALPH AUSTIN JR.
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Credential | MD
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Telephone | 478-747-9317
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 021140
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License Number State | GA
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