Provider Demographics
NPI:1336397595
Name:JEANPHIS LAGUERRE MD PC
Entity Type:Organization
Organization Name:JEANPHIS LAGUERRE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:B
Authorized Official - Last Name:RICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-891-9131
Mailing Address - Street 1:PO BOX 1838
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-1838
Mailing Address - Country:US
Mailing Address - Phone:229-891-9009
Mailing Address - Fax:229-891-9141
Practice Address - Street 1:3007B 2ND ST SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6798
Practice Address - Country:US
Practice Address - Phone:229-891-9009
Practice Address - Fax:229-891-9141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059815174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty