Provider Demographics
NPI:1922404896
Name:FASTTRACK IMMEDIATE CARE OF EASTMAN LLC
Entity Type:Organization
Organization Name:FASTTRACK IMMEDIATE CARE OF EASTMAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:NOBLES
Authorized Official - Last Name:PAULK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-271-0337
Mailing Address - Street 1:126 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:COCHRAN
Mailing Address - State:GA
Mailing Address - Zip Code:31014-6330
Mailing Address - Country:US
Mailing Address - Phone:478-271-0337
Mailing Address - Fax:478-295-3003
Practice Address - Street 1:1120 INDIAN DR STE C
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-7671
Practice Address - Country:US
Practice Address - Phone:478-374-1778
Practice Address - Fax:478-374-1727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2018-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherNPI