Provider Demographics
NPI:1376237354
Name:DOWNTOWN MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:DOWNTOWN MEDICAL CLINIC, LLC
Other - Org Name:GLAM TOWN MEDICAL & SPA LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RONDA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:COCHRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-304-0606
Mailing Address - Street 1:124 W MADISON ST STE D
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-5180
Mailing Address - Country:US
Mailing Address - Phone:478-304-0606
Mailing Address - Fax:888-375-3879
Practice Address - Street 1:124 W MADISON ST STE D
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-5180
Practice Address - Country:US
Practice Address - Phone:478-304-0606
Practice Address - Fax:888-375-3879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-05
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service