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General NPI Number Information
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NPI Number | 1780445643
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Entity Type | Organization
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Legal Business Name | DIABETES CENTER OF JESUP LLC
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Dates
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Enumeration Date | 01/18/2024
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Last Update Date | 01/22/2024
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Provider Practice Location Address
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Address Line | 124 MEMORIAL DR
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City | JESUP
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State | GA
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Zip | 31545-0101
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Country | US
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Telephone | 912-750-0011
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Fax | 833-740-4346
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Provider Business Mailing Address
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Address Line | 24 GLENDALE AVE STE E
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City | BAXLEY
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State | GA
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Zip | 31513-0245
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Country | US
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Telephone | 123-102-3839
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RANDALL CRAWFORD
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Credential | FNP
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Telephone | 912-339-2342
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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