Provider Demographics
NPI:1346590148
Name:PROVIDENCE FAMILY MEDICINE CLINIC, INC
Entity Type:Organization
Organization Name:PROVIDENCE FAMILY MEDICINE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SARITA
Authorized Official - Middle Name:DARLENE
Authorized Official - Last Name:MOBLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH, MS
Authorized Official - Phone:703-593-6154
Mailing Address - Street 1:1787 BROAD ST.
Mailing Address - Street 2:P.O. BOX 685
Mailing Address - City:LUMPKIN
Mailing Address - State:GA
Mailing Address - Zip Code:31815
Mailing Address - Country:US
Mailing Address - Phone:703-593-6154
Mailing Address - Fax:
Practice Address - Street 1:1787 BROAD STREET
Practice Address - Street 2:PROVIDENCE FAMILY MEDICINE CLINIC, INC
Practice Address - City:LUMPKIN
Practice Address - State:GA
Practice Address - Zip Code:31815
Practice Address - Country:US
Practice Address - Phone:703-593-6154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046872207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty