Provider Demographics
NPI:1679502959
Name:WARE COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:WARE COUNTY BOARD OF HEALTH
Other - Org Name:DAISY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PSO
Authorized Official - Prefix:
Authorized Official - First Name:STARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-338-5263
Mailing Address - Street 1:1720 OLD REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-1036
Mailing Address - Country:US
Mailing Address - Phone:912-285-6301
Mailing Address - Fax:912-287-6713
Practice Address - Street 1:1720 OLD REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-1036
Practice Address - Country:US
Practice Address - Phone:912-285-6301
Practice Address - Fax:912-287-6713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000052027YMedicaid
GA000453428AMedicaid
GA000442967KMedicaid
GA000777763AMedicaid
GA000457806AMedicaid
GAFLU135Medicare ID - Type UnspecifiedCOUNTY FLU BILLING #
GA000457806AMedicaid