Provider Demographics
NPI:1760005144
Name:CAMILLA MEDICAL CLINIC
Entity Type:Organization
Organization Name:CAMILLA MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KITTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-328-7593
Mailing Address - Street 1:138 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-1809
Mailing Address - Country:US
Mailing Address - Phone:229-351-4125
Mailing Address - Fax:
Practice Address - Street 1:138 E BROAD ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1809
Practice Address - Country:US
Practice Address - Phone:229-351-4125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
XXXOtherXXX