Provider Demographics
NPI:1205212917
Name:TCWC LAWRENCEVILLE LLC
Entity Type:Organization
Organization Name:TCWC LAWRENCEVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-978-0970
Mailing Address - Street 1:3157 SUGARLOAF PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-9492
Mailing Address - Country:US
Mailing Address - Phone:678-828-4114
Mailing Address - Fax:
Practice Address - Street 1:3157 SUGARLOAF PKWY STE 130
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-9492
Practice Address - Country:US
Practice Address - Phone:678-828-4114
Practice Address - Fax:404-855-4184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009505261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center