Provider Demographics
NPI:1619271103
Name:HEALTHSOURCE MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:HEALTHSOURCE MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRISTI
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:GODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:229-245-1004
Mailing Address - Street 1:1609 NORMAN DR
Mailing Address - Street 2:STE A-1
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-3753
Mailing Address - Country:US
Mailing Address - Phone:229-245-1004
Mailing Address - Fax:229-245-1074
Practice Address - Street 1:1609 NORMAN DR
Practice Address - Street 2:STE A-1
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-3753
Practice Address - Country:US
Practice Address - Phone:229-245-1004
Practice Address - Fax:229-245-1074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-27
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN130256363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty