Provider Demographics
NPI:1376222075
Name:GEORGIA TRD CLINIC, LLC
Entity Type:Organization
Organization Name:GEORGIA TRD CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MCCORMACK
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:706-316-1908
Mailing Address - Street 1:1361 JENNINGS MILL RD STE 201
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7292
Mailing Address - Country:US
Mailing Address - Phone:706-316-1908
Mailing Address - Fax:706-316-2062
Practice Address - Street 1:1361 JENNINGS MILL RD STE 201
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7292
Practice Address - Country:US
Practice Address - Phone:706-316-1908
Practice Address - Fax:706-316-2062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty