Provider Demographics
NPI:1518029966
Name:THE HEALTH DEPOT
Entity Type:Organization
Organization Name:THE HEALTH DEPOT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:POLOW
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:706-695-0561
Mailing Address - Street 1:824 GI MADDOX PKWY
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30705-2073
Mailing Address - Country:US
Mailing Address - Phone:706-695-0561
Mailing Address - Fax:706-695-8678
Practice Address - Street 1:824 GI MADDOX PKWY
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-2073
Practice Address - Country:US
Practice Address - Phone:706-695-0561
Practice Address - Fax:706-695-8678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024067261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3522Medicare ID - Type UnspecifiedCORPORATION GROUP NUMBER