Provider Demographics
NPI:1508148636
Name:LAGRANGE COLLEGE
Entity Type:Organization
Organization Name:LAGRANGE COLLEGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTACT NAME
Authorized Official - Prefix:
Authorized Official - First Name:ROB
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-880-8099
Mailing Address - Street 1:PO BOX 819020
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75381-9020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 BROAD ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2955
Practice Address - Country:US
Practice Address - Phone:706-880-8099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health