Provider Demographics
NPI:1306036892
Name:TOCCOA CLINIC MEDICAL ASSOC
Entity Type:Organization
Organization Name:TOCCOA CLINIC MEDICAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-886-7537
Mailing Address - Street 1:PO BOX 2153
Mailing Address - Street 2:DEPT 3423
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35287-3423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:274 BIG A ROAD
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-6002
Practice Address - Country:US
Practice Address - Phone:706-886-7537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0835590001OtherMEDICARE DME SUPPLIER NUM
GA0835590001Medicare NSC