Provider Demographics
NPI:1689036949
Name:RELIANCE FAMILY CARE
Entity Type:Organization
Organization Name:RELIANCE FAMILY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OM
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:RMA,CPC
Authorized Official - Phone:770-377-8874
Mailing Address - Street 1:345 HUNTINGTON PLACE CT
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-8651
Mailing Address - Country:US
Mailing Address - Phone:678-272-7280
Mailing Address - Fax:678-610-6025
Practice Address - Street 1:345 HUNTINGTON PLACE CT
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8651
Practice Address - Country:US
Practice Address - Phone:678-272-7280
Practice Address - Fax:678-610-6025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053715207Q00000X, 332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA626586339BMedicaid