Provider Demographics
NPI:1225745086
Name:INSULINIC OF GEORGIA LLC
Entity Type:Organization
Organization Name:INSULINIC OF GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-202-1023
Mailing Address - Street 1:6 PINE VALLEY RD SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-4338
Mailing Address - Country:US
Mailing Address - Phone:256-585-4221
Mailing Address - Fax:
Practice Address - Street 1:931 E WINTHROPE AVE
Practice Address - Street 2:
Practice Address - City:MILLEN
Practice Address - State:GA
Practice Address - Zip Code:30442-1839
Practice Address - Country:US
Practice Address - Phone:478-239-0230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-01
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty