Provider Demographics
NPI:1235547431
Name:LAKE OCONEE URGENT AND SPECIALTY CARE CENTER
Entity Type:Organization
Organization Name:LAKE OCONEE URGENT AND SPECIALTY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-484-0884
Mailing Address - Street 1:1881 LANCASTER DR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-6440
Mailing Address - Country:US
Mailing Address - Phone:404-405-7596
Mailing Address - Fax:
Practice Address - Street 1:105 HARMONY XING
Practice Address - Street 2:SUITE 3
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-9522
Practice Address - Country:US
Practice Address - Phone:706-484-0884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7235363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty