Provider Demographics
NPI:1962817601
Name:APPLECARE MEMORIAL IMMEDIATE CARE JOINT VENTURE LLC
Entity Type:Organization
Organization Name:APPLECARE MEMORIAL IMMEDIATE CARE JOINT VENTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-350-9335
Mailing Address - Street 1:PO BOX 671447
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-1447
Mailing Address - Country:US
Mailing Address - Phone:912-350-2121
Mailing Address - Fax:912-350-2145
Practice Address - Street 1:14089 ABERCORN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1966
Practice Address - Country:US
Practice Address - Phone:912-350-2121
Practice Address - Fax:912-350-2145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003148665AMedicaid
GA202G704077Medicare PIN