Provider Demographics
NPI:1912165887
Name:PEACH TREE CLINIC INC
Entity Type:Organization
Organization Name:PEACH TREE CLINIC INC
Other - Org Name:LIVE OAK MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:M
Authorized Official - Last Name:COULTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-741-6245
Mailing Address - Street 1:5730 PACKARD AVE
Mailing Address - Street 2:STE 600
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-7118
Mailing Address - Country:US
Mailing Address - Phone:530-741-6245
Mailing Address - Fax:530-743-5044
Practice Address - Street 1:5730 PACKARD AVE
Practice Address - Street 2:STE 600
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-7118
Practice Address - Country:US
Practice Address - Phone:530-741-6245
Practice Address - Fax:530-743-5044
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEACH TREE CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1316096894Medicaid