Provider Demographics
NPI:1679958003
Name:N/A AT PRESENT TIME, WILL BE WORKING CONTRACTPRIVATEDUTY
Entity Type:Organization
Organization Name:N/A AT PRESENT TIME, WILL BE WORKING CONTRACTPRIVATEDUTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CNA
Authorized Official - Prefix:MISS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTS
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED NURSING AS
Authorized Official - Phone:706-333-9369
Mailing Address - Street 1:401A BOULEVARD
Mailing Address - Street 2:401ABOULEVARD
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-3009
Mailing Address - Country:US
Mailing Address - Phone:706-333-9369
Mailing Address - Fax:
Practice Address - Street 1:401A BOULEVARD
Practice Address - Street 2:401ABOULEVARD
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3009
Practice Address - Country:US
Practice Address - Phone:706-333-9369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0000047840251J00000X
ALCN0000047840376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251J00000XAgenciesNursing CareGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty