Provider Demographics
NPI:1245314780
Name:J PARKS MEDICAL LLC
Entity type:Organization
Organization Name:J PARKS MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-538-5734
Mailing Address - Street 1:320 BROWN DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:GA
Mailing Address - Zip Code:30527-1753
Mailing Address - Country:US
Mailing Address - Phone:770-538-5734
Mailing Address - Fax:
Practice Address - Street 1:1010 DAWSONVILLE HWY
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2621
Practice Address - Country:US
Practice Address - Phone:770-533-8329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018176314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000114287DMedicaid
GA000114287EMedicaid
GA000114287EMedicaid
GAD40812Medicare UPIN