Provider Demographics
NPI:1871894246
Name:MAC-LUMPKIN RD LLC
Entity type:Organization
Organization Name:MAC-LUMPKIN RD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-660-6155
Mailing Address - Street 1:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-1038
Mailing Address - Country:US
Mailing Address - Phone:706-571-1976
Mailing Address - Fax:706-660-6512
Practice Address - Street 1:1627 S LUMPKIN RD
Practice Address - Street 2:SUITE 6
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31903-2719
Practice Address - Country:US
Practice Address - Phone:706-243-4154
Practice Address - Fax:706-243-4154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center