Provider Demographics
NPI:1174836753
Name:ATHENS IMMEDIATE CARE #1, LLC
Entity Type:Organization
Organization Name:ATHENS IMMEDIATE CARE #1, LLC
Other - Org Name:SMARTERCLINIX OF ATHENS #1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-471-5308
Mailing Address - Street 1:1010 PRINCE AVE
Mailing Address - Street 2:SOUTH BUILDING
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-5805
Mailing Address - Country:US
Mailing Address - Phone:706-850-8200
Mailing Address - Fax:706-850-8250
Practice Address - Street 1:1010 PRINCE AVE
Practice Address - Street 2:SOUTH BUILDING
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5805
Practice Address - Country:US
Practice Address - Phone:706-850-8200
Practice Address - Fax:706-850-8250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty