Provider Demographics
NPI:1639580186
Name:MUMFORD TELEHEALTH SERVICES
Entity Type:Organization
Organization Name:MUMFORD TELEHEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:PENNICA
Authorized Official - Middle Name:MUMFORD
Authorized Official - Last Name:MUMFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:912-844-6497
Mailing Address - Street 1:4113 FENWICK VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-5513
Mailing Address - Country:US
Mailing Address - Phone:912-844-6497
Mailing Address - Fax:
Practice Address - Street 1:4113 FENWICK VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-5513
Practice Address - Country:US
Practice Address - Phone:912-844-6497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-17
Last Update Date:2014-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN168735251J00000X, 251K00000X, 251S00000X, 252Y00000X, 253Z00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251J00000XAgenciesNursing Care
No251K00000XAgenciesPublic Health or Welfare
No252Y00000XAgenciesEarly Intervention Provider Agency
No253Z00000XAgenciesIn Home Supportive Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health