=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962516120
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERTOWN MEDICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2006
-----------------------------------------------------
Last Update Date | 06/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4328 ARMOUR RD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31904-5204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-507-1213
-----------------------------------------------------
Fax | 706-507-1217
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4328 ARMOUR RD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31904-5204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-507-1213
-----------------------------------------------------
Fax | 706-507-1217
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCOTR
-----------------------------------------------------
Name | DR. KEVIN DONALD LOKKESMOE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 706-507-1213
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | GA032941
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------