Provider Demographics
NPI:1275724486
Name:LONG HAUL CLINIC, LLC
Entity Type:Organization
Organization Name:LONG HAUL CLINIC, LLC
Other - Org Name:ROADSIDE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAREGEANNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-749-7803
Mailing Address - Street 1:10945 STATE BRIDGE RD
Mailing Address - Street 2:SUITE 401, ROOM 358
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-8164
Mailing Address - Country:US
Mailing Address - Phone:678-749-7803
Mailing Address - Fax:
Practice Address - Street 1:10945 STATE BRIDGE RD
Practice Address - Street 2:SUITE 401, ROOM 358
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-8164
Practice Address - Country:US
Practice Address - Phone:678-749-7803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care