Provider Demographics
NPI:1912528696
Name:PITTARD CLINIC LLC
Entity Type:Organization
Organization Name:PITTARD CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIDAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:PITTARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-886-4420
Mailing Address - Street 1:1654 FALLS RD
Mailing Address - Street 2:
Mailing Address - City:TOCCOA
Mailing Address - State:GA
Mailing Address - Zip Code:30577
Mailing Address - Country:US
Mailing Address - Phone:706-886-4420
Mailing Address - Fax:706-886-4410
Practice Address - Street 1:1654 FALLS RD
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577
Practice Address - Country:US
Practice Address - Phone:706-886-4420
Practice Address - Fax:706-886-4410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone