Provider Demographics
NPI:1629765052
Name:ALFORD, DEMETRICUS LASALLE (RN)
Entity Type:Individual
Prefix:
First Name:DEMETRICUS
Middle Name:LASALLE
Last Name:ALFORD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N SLAPPEY BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1409
Mailing Address - Country:US
Mailing Address - Phone:855-933-0957
Mailing Address - Fax:
Practice Address - Street 1:690 PINE AVE
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-2655
Practice Address - Country:US
Practice Address - Phone:229-815-2256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN296009261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care