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General NPI Number Information
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NPI Number | 1992910749
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Entity Type | Organization
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Legal Business Name | K12 CLINICS
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 07/09/2009
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Provider Practice Location Address
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Address Line | 938 ELMA G. MILES PARKWAY
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City | HINESVILLE
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State | GA
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Zip | 31313
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Country | US
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Telephone | 912-877-7924
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Fax | 912-877-5437
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Provider Business Mailing Address
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Address Line | 938 E.G. MILES PARKWAY
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City | HINESVILLE
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State | GA
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Zip | 31313
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Country | US
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Telephone | 912-877-7924
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Fax | 912-877-5437
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. ADEREMI S. DOSUNMU
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Credential | M.D.
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Telephone | 912-877-7924
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 047893
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 047893
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 047893
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License Number State | GA
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