Facts
- Status
- A
- Credential
- PAC
- Type
- Individual
- Enumeration date
- 2006-07-28
- Last updated
- 2015-04-24
Specialties
Licenses
- License GA
- 003472
Location
- Practice location
- 905 N COURT ST
- City
- QUITMAN GA
- Postal code
- 31643
- Phone
- 229-263-8956
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.