=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912454869
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOCUSED CARE OF GEORGIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2016
-----------------------------------------------------
Last Update Date | 09/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2410 INGLESIDE AVE
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31204-2036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-345-8056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2410 INGLESIDE AVE
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31204-2036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-345-8056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. STEPHEN BARRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 478-345-8056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------