Provider Demographics
NPI:1760668586
Name:ENTERPRISE FAMILY HEALTHCARE
Entity Type:Organization
Organization Name:ENTERPRISE FAMILY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARRELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-745-9559
Mailing Address - Street 1:2192 INGLESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2030
Mailing Address - Country:US
Mailing Address - Phone:478-745-9880
Mailing Address - Fax:478-745-8611
Practice Address - Street 1:2192 INGLESIDE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2030
Practice Address - Country:US
Practice Address - Phone:478-745-9880
Practice Address - Fax:478-745-8611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040767261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4689OtherMEDICARE GROUP NUMBER
GAH45915Medicare UPIN