Provider Demographics
NPI:1477913580
Name:SOUTHLAND OPTIM JENKINS EMERGENCY MEDICAL SERVICES, LLC
Entity Type:Organization
Organization Name:SOUTHLAND OPTIM JENKINS EMERGENCY MEDICAL SERVICES, LLC
Other - Org Name:DBA SOUTHLAND LIBERTY EMERGENCY MEDICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:229-520-7115
Mailing Address - Street 1:100 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5473
Mailing Address - Country:US
Mailing Address - Phone:229-236-0831
Mailing Address - Fax:229-236-0871
Practice Address - Street 1:455 S MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-4354
Practice Address - Country:US
Practice Address - Phone:912-369-4673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty