Provider Demographics
NPI:1326387820
Name:WINGARD PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:WINGARD PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:B
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-692-7575
Mailing Address - Street 1:1325 COMMERCE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3582
Mailing Address - Country:US
Mailing Address - Phone:770-692-7575
Mailing Address - Fax:770-692-7570
Practice Address - Street 1:510 SWANSON RD
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-6900
Practice Address - Country:US
Practice Address - Phone:770-964-5230
Practice Address - Fax:770-964-5260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207Q00000X
207Q00000X
GA056526261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care