Provider Demographics
NPI:1205062130
Name:MARY LOU'S GARDEN, INC.
Entity type:Organization
Organization Name:MARY LOU'S GARDEN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAIMEE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CFM
Authorized Official - Phone:706-310-7175
Mailing Address - Street 1:PO BOX 1723
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-0034
Mailing Address - Country:US
Mailing Address - Phone:706-310-7175
Mailing Address - Fax:706-310-7176
Practice Address - Street 1:10 S BARNETT SHOALS RD
Practice Address - Street 2:SUITE C.
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-6711
Practice Address - Country:US
Practice Address - Phone:706-310-7175
Practice Address - Fax:706-310-7176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-05
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAINV-8-06-988335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6219560001Medicare NSC