Provider Demographics
NPI:1205207933
Name:OUR LADY OF THE ROSES PRIMARY CARE
Entity Type:Organization
Organization Name:OUR LADY OF THE ROSES PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WIECZOREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-327-4880
Mailing Address - Street 1:PO BOX 1957
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-1957
Mailing Address - Country:US
Mailing Address - Phone:706-587-5771
Mailing Address - Fax:
Practice Address - Street 1:808 21ST ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8817
Practice Address - Country:US
Practice Address - Phone:706-587-5771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN042301261QM1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1000XAmbulatory Health Care FacilitiesClinic/CenterMigrant Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000901106DMedicaid
AL126693Medicaid
GA000901106DMedicaid