=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952363301
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HENRY COUNTY COMMISSIONER OF ROADS AND REVENUES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2006
-----------------------------------------------------
Last Update Date | 06/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 S ZACK HINTON PKWY
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253-3353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-288-6536
-----------------------------------------------------
Fax | 770-288-6544
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 S ZACK HINTON PKWY
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253-3353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-288-6536
-----------------------------------------------------
Fax | 770-288-6544
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AMBULANCE BILLING MGR
-----------------------------------------------------
Name | JENNY JENKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-288-6688
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 075-03
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------