Provider Demographics
NPI:1831152503
Name:BOATWRIGHT-MCRAE CLINIC
Entity type:Organization
Organization Name:BOATWRIGHT-MCRAE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:VANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-523-5113
Mailing Address - Street 1:441 N W BROAT ST
Mailing Address - Street 2:
Mailing Address - City:MTVERNON
Mailing Address - State:GA
Mailing Address - Zip Code:30428
Mailing Address - Country:US
Mailing Address - Phone:912-583-2229
Mailing Address - Fax:
Practice Address - Street 1:441 N W BROAT ST
Practice Address - Street 2:
Practice Address - City:MTVERNON
Practice Address - State:GA
Practice Address - Zip Code:30428
Practice Address - Country:US
Practice Address - Phone:912-583-2229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000002076EMedicaid
GA000002076EMedicaid