Provider Demographics
NPI:1831426931
Name:KENNESAW STATE UNIVERSITY HEALTH CLINIC
Entity type:Organization
Organization Name:KENNESAW STATE UNIVERSITY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:770-423-6644
Mailing Address - Street 1:1000 CHASTAIN RD NW
Mailing Address - Street 2:HOUSE 52
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5588
Mailing Address - Country:US
Mailing Address - Phone:770-423-6644
Mailing Address - Fax:
Practice Address - Street 1:1000 CHASTAIN RD NW
Practice Address - Street 2:HOUSE 52
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5588
Practice Address - Country:US
Practice Address - Phone:770-423-6644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN057224261QS1000X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health