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General NPI Number Information
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NPI Number | 1780879957
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Entity Type | Organization
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Legal Business Name | DOERUN HEALTHCARE L.L.C.
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Dates
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Enumeration Date | 09/11/2007
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Last Update Date | 09/11/2007
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Provider Practice Location Address
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Address Line | 217 WEST BROAD AVE
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City | DOERUN
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State | GA
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Zip | 31744-0459
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Country | US
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Telephone | 229-782-5048
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Fax | 229-782-5049
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Provider Business Mailing Address
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Address Line | 217 WEST BROAD AVE PO BOX 459
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City | DOERUN
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State | GA
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Zip | 31744-0459
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Country | US
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Telephone | 229-782-5048
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Fax | 229-782-5049
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Authorized Official
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Title or Position | PRESIDENT
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Name | THOMAS ALEXANDER MAC KEAN
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Credential | FNP-C
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Telephone | 229-782-5048
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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 | RN146046
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License Number State | GA
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