Provider Demographics
NPI:1346893799
Name:TEMPLE MEDHEALTH
Entity Type:Organization
Organization Name:TEMPLE MEDHEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRANDERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIWA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:765-326-0148
Mailing Address - Street 1:503 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1931
Mailing Address - Country:US
Mailing Address - Phone:770-462-1170
Mailing Address - Fax:
Practice Address - Street 1:503 MAIN ST
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1931
Practice Address - Country:US
Practice Address - Phone:770-462-1170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1447790530Medicaid