Provider Demographics
NPI:1487837134
Name:LAURENS COUNTY VOLUNTEERS IN MEDICINE
Entity Type:Organization
Organization Name:LAURENS COUNTY VOLUNTEERS IN MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:O
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:478-272-3446
Mailing Address - Street 1:4132 DUNMORE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33859-5742
Mailing Address - Country:US
Mailing Address - Phone:863-324-1580
Mailing Address - Fax:
Practice Address - Street 1:1506 TELFAIR ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-3908
Practice Address - Country:US
Practice Address - Phone:478-272-3446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009683261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)