Provider Demographics
NPI:1710543533
Name:AZALEA CITY HEARTS
Entity Type:Organization
Organization Name:AZALEA CITY HEARTS
Other - Org Name:THOMAS HART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NP/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:229-560-0252
Mailing Address - Street 1:4510 MAHAN DR
Mailing Address - Street 2:
Mailing Address - City:HAHIRA
Mailing Address - State:GA
Mailing Address - Zip Code:31632-2616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4510 MAHAN DR
Practice Address - Street 2:
Practice Address - City:HAHIRA
Practice Address - State:GA
Practice Address - Zip Code:31632-2616
Practice Address - Country:US
Practice Address - Phone:229-560-0252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-16
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care