Basic Information
| Provider Information | |||||||||
| NPI: | 1679946669 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 UPPER RIVERDALE RD SW | ||||||||
| Address2: | |||||||||
| City: | RIVERDALE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302742615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709918000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11 UPPER RIVERDALE RD SW | ||||||||
| Address2: | |||||||||
| City: | RIVERDALE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302742615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709918000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2015 | ||||||||
| LastUpdateDate: | 11/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | DOAN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 9092354307 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRIME HEALTHCARE FOUNDATION - SOUTHERN REGIONAL, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | GA | Y | Hospital Units | Rehabilitation Unit |
No ID Information.