Provider Demographics
NPI:1700042553
Name:SOUTHLAND BRANCH FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:SOUTHLAND BRANCH FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:C
Authorized Official - Last Name:LAING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-928-4144
Mailing Address - Street 1:PO BOX 546
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-0546
Mailing Address - Country:US
Mailing Address - Phone:229-928-4144
Mailing Address - Fax:229-928-3410
Practice Address - Street 1:151 MAYO ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3735
Practice Address - Country:US
Practice Address - Phone:229-928-4144
Practice Address - Fax:229-928-3410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN127193363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty