Provider Demographics
NPI:1649856493
Name:HEALING OAKS LLC
Entity type:Organization
Organization Name:HEALING OAKS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:B
Authorized Official - Last Name:VICKERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-378-0328
Mailing Address - Street 1:PO BOX 5554
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-0290
Mailing Address - Country:US
Mailing Address - Phone:770-378-0328
Mailing Address - Fax:770-604-1929
Practice Address - Street 1:203 OAKSIDE LN STE C
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-6407
Practice Address - Country:US
Practice Address - Phone:770-604-1930
Practice Address - Fax:770-604-1929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA773092643FMedicaid