Provider Demographics
NPI:1952584708
Name:DIVERSITY HEALTH CENTER INC
Entity Type:Organization
Organization Name:DIVERSITY HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES-THEAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-318-3947
Mailing Address - Street 1:P.O. BOX 1520
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31310
Mailing Address - Country:US
Mailing Address - Phone:912-545-9398
Mailing Address - Fax:912-545-2747
Practice Address - Street 1:213 N MCDONALD ST STE A&B
Practice Address - Street 2:
Practice Address - City:LUDOWICI
Practice Address - State:GA
Practice Address - Zip Code:31316
Practice Address - Country:US
Practice Address - Phone:912-545-9398
Practice Address - Fax:912-545-2747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA023448459AMedicaid
GA023448459AMedicaid