Provider Demographics
NPI:1184394611
Name:MAD BIRD DAWG, INC.
Entity type:Organization
Organization Name:MAD BIRD DAWG, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:FOCKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-866-5334
Mailing Address - Street 1:1411 MARY ELLEN DR
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-7982
Mailing Address - Country:US
Mailing Address - Phone:770-866-5334
Mailing Address - Fax:
Practice Address - Street 1:725 CHERRY RD STE 140
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3143
Practice Address - Country:US
Practice Address - Phone:803-818-2120
Practice Address - Fax:803-818-2119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center