Provider Demographics
NPI:1487854345
Name:WEST GEORGIA MULTI SPECIALTY CLINIC, PC
Entity Type:Organization
Organization Name:WEST GEORGIA MULTI SPECIALTY CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-845-0931
Mailing Address - Street 1:106 LUKKEN INDUSTRIAL DR W
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-5912
Mailing Address - Country:US
Mailing Address - Phone:706-882-8128
Mailing Address - Fax:706-883-8638
Practice Address - Street 1:106 LUKKEN INDUSTRIAL DR W
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-5912
Practice Address - Country:US
Practice Address - Phone:706-882-8128
Practice Address - Fax:706-883-8638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014313208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty