Provider Demographics
NPI:1558544684
Name:BEULAH GROVE COMMUNITY RESOURCE CENTER
Entity Type:Organization
Organization Name:BEULAH GROVE COMMUNITY RESOURCE CENTER
Other - Org Name:LAMAR MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-722-4999
Mailing Address - Street 1:1448 LEE BEARD WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-3414
Mailing Address - Country:US
Mailing Address - Phone:706-828-7468
Mailing Address - Fax:706-724-7566
Practice Address - Street 1:1448 LEE BEARD WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-3414
Practice Address - Country:US
Practice Address - Phone:706-828-7468
Practice Address - Fax:706-724-7566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2739Medicare PIN