Provider Demographics
NPI:1467612952
Name:PALMETTO HEALTH COUNCIL INC
Entity Type:Organization
Organization Name:PALMETTO HEALTH COUNCIL INC
Other - Org Name:YOURTOWN HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:W
Authorized Official - Last Name:WOLLENZIEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DBA
Authorized Official - Phone:404-929-8824
Mailing Address - Street 1:643 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-1138
Mailing Address - Country:US
Mailing Address - Phone:404-929-8824
Mailing Address - Fax:404-929-9769
Practice Address - Street 1:202 CROFT ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3803
Practice Address - Country:US
Practice Address - Phone:770-834-2255
Practice Address - Fax:770-834-7100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAH800040207Q00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000472128GMedicaid
GA000472128GMedicaid
GA000472128GMedicaid